GW1-2022-10276_Well Construction - GW1_20221114

17V ELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
PR0,11 TO DESCRIPTION
Well Contractor Name.
6 3 b' -- 6 (o
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR L1NER rf a lieabic
1 FRODt TO DIAMETER THICKNESS �iATER1AL
r(l �� 0 Is- Q% (0Ie in.
Company Name 16.INNER CASING OR!!!TUBING geothermal closed-loop)
1919 9 FROM TO DIAMEnR THICKNESS MATERLIL
Z.Well Construction Permit: . � ft. ft in.
List all applicable well constnictlon permits(i.e.County.State, Variance,etc.) ft. in.
3.Well Use(checll well use): ft.17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATEIUAL
❑Agricultural ❑MtrnicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr. Is. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
��� FROM TO ��b
EMPLACEMENT METHOD •AMOUNT
Nn;Wate Cj rt. d I't. 1v u e
Non-Water Supply Well:
rc. rc.
❑Monitoritlg ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Ground�(wa�jtP�eaniq 19.SANDIGRAVEL PACK(ifa licable)
❑Aquifer Storage and Recovery ❑Salinij-Rilri FROM rL ft.TO INMNERIAL I EMPLACE\IENTMETHOD
OAquifer Test ❑Stotmwater a e r}. 2�22
ft. ft.
❑i xperimental Technology ❑Subsidence'Cbh(r((����((��o
c ,• �- „ 1, 20.DRILLING LOG(attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer
1f1�frll3a(�1 t rY3 e+ FROM TO DESCRIPTION(color,hardness.solVrock e,grain size,eta)
❑Geothermal(Heating/Cooling Retu�(m) ❑Other(explain l aI'�ertrlr-'Va''@narks) O rr. ft-
4.Date Well(s)Completed: Z U ;�
D ft. ft.
5.Well Location: k; ft. 6 FL
ixt J
19091eY vRO6 rr. 360 rt, RA ! C
Facility/Owner Name Facility IDff(ifapplicable) ft. ft.
16 9 3(-1 (20Nrve)1- Rd fL
Nysical/Addd�ress,Cit),,and ZZiilp � 11 21.REi4IARICS
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
S itmatsWof Certified Well Coramctor Date
6.Is(are)the well(s): Permanent or ❑Temporary
Its,sigrmng this forum. f hereby certify that the well(s)was(wcre)constructed in accordance
with 15.4 NCAC 02C.0100 or 15.1 NCAC 02C.0200 Drell Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or b4 copy ofthis r•eca•d has been provided to the well owner.
ljihfs is a repair,fill out known well construction information and eyplain the nature ojthe
repair under P21 remarks-section or o,the back ofthis joml. 23.Site diagram or additional well details:
u You may use die back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
rar multiple hgection or non-water supply mrells ONLY with the sauna construction,you call
subunit oneform. �pp 24.Submittal Instructions:
9.Totul-)yell depth below land surface: 360, (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ffdii fezeni(erannple-3Q200'and,,2aa©100') construction(o the following:
F 10.Static water level below top of casing: V (ft-) Division of Water Quality,Information Processing Unit,
lfrater level is above casing.use.,+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Q (in.) 241). For Injection Wells: In addition to sending the form to the address in 24a
n above, also subunit a copy of this form within 30 days of completion of well
12.Well co truction method: I / , construction to the following:
(i.e.auger rotor)•, able,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water SunnhV&Geothermal 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 qTe: Amount: NT completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013