GW1-2022-09346_Well Construction - GW1_20221010

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only
1.Well Contractor Information:
Well CotnnctorName FROM TO DESCRIPTION"
SC & et,
NC Well Contractor Certification Number 2 `OLr175R`.C?ISIIYG` `r'mnttt �ive _'oR` >ivnit a'EEab)e
W `.y^��� ` FROM TO DIAMETER THICKN� MATERIAL
VV 1"TC C�V` VVV 1 `lam fr. � ft. (f t�. S PV
Company Name .`16.INNER CASING.ORT[JBINGfaeothirmid crem"001
2.Well Construction Permit : FROM I TO I DiAMi M I THICIWESs MATERIAL
list all applicable well construction permits(i e.UIC,County.State,Variance.etc.) fL fL in.
3.Well Use(check well e): ft.
us ft. in.
Water Supply Well:
'17.SCREEN:' ;,.
FROM TO DIAMETER SLOT SIZE TMCHNffiS MATERIAL
_. Agricultural DM crpal/Public U ft. & in.
Geothermal(Heating/Cooling Supply) Mfesidential Water Supply(single) fL M tn.
Industrial/Commercial DResidential Water Supply(shared) i&GROUT
Irrigation FROM TO MATERIAL. F"LACEMEgff MEMOi)&AMOUNT
Non-Water Supply Well: ft- Lt-7 I �E $
3—Monitoring {Recovery M ft.
Injection Well:
ft. ft.
JAquifer
quifer-Recharge E3Groundwater Remediation 19.SANINGRAVEL PACtc a
,.acebie
quifer Storage and Recovery Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Test Stomtwater Drainage ft• ft.
xperimental Technology Subsidence Control ft. ft-
eothermal(Closed Loop) Tracer 20.1)RILLING LOG attach additional sheets ffeothermal eatin Coolin Retum) Other(explain under#21 Remarks FROM TO D&SCRiPTION(Color,hardnea.suil/roek ere
a� ft. ft.
4.Date Well(s)Compieted: '`''~ `Well ID# ft. ft.
5a.Well Location:
�.'
J,eff �0 p ft. ft.
Facility/Owner(Name (��" f (� Facility ID9(if amlilicaab�le) fL M
t OV 1 Wl6.t' 1`A �(�I.eV1.�. I Ali ft. ft. -•1 . :^;r:" 1Ei ..
�E
Physical Address,City,and Zip fL ft.1. E r
21.RE
County 4 Parcel Identification No.(PIN) S `
Sb.Latitude and longitude in degrees/arinutes/seconds or decimal degrees:
(if w It field,one lat/long is sufficient) 22.Certification:
t�.o " No7�'36It °�3 / �6tt�3ld�r
6.Is(are)the well _s) Permanent or OTempoLary Si of Certified well Contractor Date
4 signing this form,I hereby certify that inft)was(were)constructed in accordance
7.Is this a repair to an existing well: M es or E3No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out brown well construction information and explain the nature of the copy of this record has been provided to the well miner.
repair under#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; I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 12� (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 00'and 2@100) construction to the following: '
10.Static water level below top of casing: �� (ft.) li"lon of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: (in) 24b.For Infection 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: r4n f` construction to the following:
(Le.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 27091636
13a.Yield(gpm) Method of test: 24c.For Water Sarah&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed,
Form GW-1 Notch Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22-2016