GW1-2022-08840_Well Construction - GW1_20220829

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
So in O'e� 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
— ft. ft.
NC Well Contractor Certification Number M OUTER'CASING for triulti-cased'irens OR LINER If a llcnble
1��f I _ I C^�S FROM TO DIAMETER THICKNESS MATERIAL
�J ��J Z-� V Cr © ft. 3 ft. in. ,W 2
Company Name 16.INNER CASING OR TUBING eothertnal dosed-loop).
2.Well Construction Permit#• FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. is
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural tZidential
icipal/Public 0 ft. ft. in.
_ Geothermal(Heating/cooling Supply) Water Supply(single) ft. ft. is
Industrial/Commercial DResidential Water Supply(shared) is.GROUT
Irrigation orlon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft 3 f" 3/ hAr to
Monitoring E3Recovery ft. ft. _ e ,
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery nSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stonnwater Drainage ft. ft.
i Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) E3Tracer 20.DRILLING LOG attach additional sheets if n
i Geothermal (Heating/Cooling Return) i_' Other(explain under#21 Remarks) FROM I To DESCRIPTION(color,hardness;soilt ock type, n sia,eta
(9 ft. It. l 1 rPIN
'4.Date Well(s)Completed: >�'-2-1 Well ID# 7 ft. Z ft. ��1 C e c
5a.Well Location: ft. t.
32
ft. rt.
Facility/Owner Name Facility ID#(if applicable) ft.
/J -1 �%J /�LI�1✓I 1�C V. IC/ /�6 / L(
Physic Address,City,and Zip ft. ft. A IJ 3 v
21.REMARKS
County Parcel Identification No.(PIN) n,a'J; 0 G
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 72.Ce77ti
N -7 Zq- ?3y_ 11 W - �r-^�•Zl
6.Is(are)the well(s)OP6rnranent or OTemporary Signa of Certified Well-Cokrfiefor Date
� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or � with 15A NCAC 02C.0100 or 15A AICAC 02C.0200 Nell Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair tinder#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (fL) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(Qa 200'and 2@100) construction to the following.
10.Static water level below top of casing: 2 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" / 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
�( above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: ✓`d ('1 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2— Method of test: IS 10 L.1 rn r^ .21c.For Water Snaply&Iniection Wells: In addition to sending the form to
I the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: LIT Amount: !S_0"rt r r S completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Euviroamental Quality-Division of Water Resources Revised 2-22-2016