GW1-2022-09217_Well Construction - GW1_20220906

WELL CONSTRUCTION RECORD (GWJ1 For Internal Use Only: Print Form
1.Well Contractor Information:
I(5o n 14.WATERZONES
Well Contractor Name FR M TO DESCRIPTION
t cw C' L�
NC Well Contractor Certification Number 15.
UTER CASINGfor multi-eased ORLINER ifalicable
OF M T DIAMETER THICKNE
MATERIAL
in. `'
Company Name t� � 1 c Y
16.INNER CASING OR TUBING( eothermal closed-loon)
2.Well Construction Permit#: FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.CIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): tt. ft. in.
Water Supply Well: 17. CREEN
FROM I TO I DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) VResidential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared) 18.PROUT
IITt atlon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. t ft. R _
Monitoring ®Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19. AND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL. I EMPLACEMENT METHOD
Aquifer Test [3Stom)water Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Mother(explain under#21 Remarks) FROM I To DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ft. 1 ft.
4.Date WeII(S)Completed:1 -3t-_0_Q Well ID# l ft. 1 ft.
5a Well Location: ft. ft.
1
�Ac ft. ft.
Facility/Ow er Name Facility ID#(if applicable)
Cr
Physical Addr s,City,and Zip
r 1AQ
21. MARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification:
G
N �'IJig
^�
6.Is(are)the well(s) Permanent or Temporary e of Certified Well Contractor Date
ng this,lbrin,I hereby certify that the well(s)was(were)constructed in ac•c•ordanc•e
7.Is this a repair to an existing well: ®Yes or No NC.4C 02C.0100 or 15A NC.4C 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information n ;plain thenature q/'thehis record has been provided to the well owner.
repair under#21 remarks section or on the back of this/brm.
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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: '',w,tt,^�1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:(317)ll� (ft.) 24a. �or All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dtf Brent(example-3(a200'and 2(rb,100') construction to the following:
10.Static water level below top of casing: 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 Infection Wells: In addition to sending the form to the address in 24a
e t� above also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1 " construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) f
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) t� Method of test: I 24c.for Water Supply& Injection Wells: In addition to sending the for))to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: mount: completion of well construction to the county health department of the county
where!constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016