GW1-2022-09081_Well Construction - GW1_20220926

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: j
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1.nWell Contractor Information:
114.WATER ZONES
�. 'i....,FROM TO DESCRIPTION
WellContm or Name / ft (Q t-f' ft &.
S F P 2022 ft 1 76 ft f
PM
NC Well Contractor Certification Number L i ,15.OUTER CASING for multi caseU wells)OR LINER ifs licable
�1 f FROM TO DIAMETER THICKNESS MATERIAL
TT 0) 5 1 I� 1 h� c'` ` L ft 3 I It
`��in.
Company Name d 16.INNER CASING OR TUBING eothermal closed400
2.Well Construction Permit#: 71�(o 9 ;i( i FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State,Variance,etc.) R• it in.
F ..
3.Well Use(check well use): fL it in.
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Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft in.
❑Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) rt ft. io,
❑Industrial/Commercial ❑Residential Water Supply(shared) I
18.GROUT
0iffigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUM
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery ft ft
injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. M
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Coohng Return) ❑Other(explain under#21 Remarks) FROM TO DESCRUMON(color,hardness,soilfrock type,grain size,etc I
n- t s f �e e� ;0I
4.Date Well(s)Completed: �'� a} Well iD# ?)(A ai(p I IL S' ft utit.f'e-
5a.lWell Location: ft it
�jo�hy e dJaVwi1e �ri S e n
�Facility/06erNaTne - Facility iD#(if
`applicable) ft ft
I\Ore e k �c ne— 4tyiA"C."011, I�r C X-1 S 3-7 ft. Its
Physical Address,City,and Zip ft
` it
v�C� (D?t COI D f b� 2L REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient) 22.Ejlcadon
Y
?��• �J� `i"03 N fig • �� �)� I W4tAI'61
6.is(are)the well(s): Permanent or ❑Temporary Signature of C4tifiSd Wel gntractor Date
By signing this form,l hereby certify that the U(s)was(were)constructed in accordance with
.7.Is this a repair to ba existing well: ❑Yes or �No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill oul own well construction information and explain the nature of the oJ'this record has been provided to the well owner.
repair under#21 remarKs section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe4p'T or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only i GW-1 is needed. indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL TNSTRUCTiUNS
9.Total well depth below land surface: 5 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3(a)200'and 2@100')
10.Static water level below top of casing Ao (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+- }
11.Borehole diameter: (O (in,) 24b.For injection Wells: Copyto DWR,Underground injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: P-0 7-�9-P 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLSONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) (> Method of test Permit Program,1611 MSC,Rale I igh,NC 27699-1611
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13b.Disinfection type:�I � 1or.( Amount:
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Form GW-I North Carolina Department of Environmental Quahty-Division of Water Resources Revised 6-6-2018
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