GW1-2022-09368_Well Construction - GW1_20221010

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
i
-S"01n Cr&AL
Weil Contractor Name FROM TO DESCRIPTION3 1 R- fL 1
"71 -c ft. ft.
NC Well Contractor Certification Number '7s;0[JT_ER'ChgTG'"for nlalit` ire Uit lslPiElt tC, ue`able "'"`"
1^' FROM O DIAMETER THICKNESS I MATERIAL
Y c, ft. JS ft. in. P
Company Name I&INNER CASING.OR TUBING""eottiei�mel•rlosed-loo
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. I in
:--173CREEN,' -
Water Supply Wen: FROM To DIAMETER SLOT SIB THICKNESS MATERIAL
Agricultural �M tpal/Public ft. ft. io•
Geothermal(Heating/Cooling Supply) esidemial Water Supply(single) ft, ft, ;n
Industrial/Commercial E3Residcntial Water Supply(shared) '1&GROUT
Irri ation FROM MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft' ft- 1
Monitoring _Recovery ft• ft•
Injection Well:
Aquifer Recharge Groundwater Remediation
d9$ANWGRAOEI:PI\t i� �f a"Iicetile
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test C)Stormwater Drainage ft. ft.
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) [)Tracer 20.,DP.MILJ VG?LOG:inach addit!6nitsheets if "
I
Geothermal(Heating/CoolingRetum Other(explain under#21 Remarks FROM TO DESCRIPTION color 6ardn soiv�odc etc
ft. ft.
4.Date Wen(s)Completed:9)�✓o`t/
1 �,,`Well W# 2 ft. ttt.
ft. ft..
Sa+.'Well Location:
C(,llo e +c; C�fZc� OCT 1
``Facility/Owner Name e J Q Fac 'ty DD#(if appli blee) ft. ft. L
ft. ft. Er•, , ,iJ i :^ �:,g 1�r,i(
Physical Address,City,and Zip
ft. ft.
Co ty a Parcel Identification �� 1
5b.Latitude and longitude in degrees/minntes/seconds or decimal degrees:
(if well field,one latAong is sufficient) 22.Certification: 22
60 w I ,1 N 7�0 ®� t �. CI W I�VIv ��
6.Is(are)the wells) Permanent or OTemporary SignqgreofCertified Well Contractor' Date
By signing this form,1 hereby ceruty'that t 11(s)was(were)constructed in accordance
7.Is this a repair to an existing well: or E]No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well 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 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 10�5 (R-) 24a.For An Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-30a 200'and 2@100) Construction to the following:
10.Static water level below top of casing: - (fL) 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 Injection 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: 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) I Method of test: At 3 24c.For Water Snarpl &Iniection Wells: In addition to sending the fort to
Z the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: J CM A fiV4 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
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