GW1-2022-10610_Well Construction - GW1_20221122

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1. ll Contractor Information:
� 6
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
NC Well Contractor Certification Number
OUTER CASING(for multi-cased wells)OR LINER(if a livable)
FROM TO DIAMETER THICKNESS/ MATERIAL
ft. ft. in. JQ s7Q
Company Name 16.INNER CASING OR TUBING('eothermal closed-loop) .
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) n R in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.FROM SCREENTO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural ElMunicipal/Public et. ft. in.
Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft g, in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
—Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. p
Monitoring 01re.overy
Injection Well:
ft. ft.
Aquifer Recharge QGroundwater Remediation
'19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
i"I Experimental Technology OSubsidence Control
Geothermal(Closed Loop) ElTracer 20.DRILLING LOG'(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) L'Other(explain under#21 Rem s)ark FROM To DESCRIPTION(color,hardness,soil/rock rain size,etc.)
ft. ft.
4.Date Well(s)Completed: Well ID#
5-a.Well Location: r
,f�� L . L.� ft. ft. NOV�V Lr 2�2�
Facility/Owner Name Facility ID#(if applicable)72
nr JJ�
Physical Address,City,and Zi ft. ft.
Aq 3 �� 21.REMARKS 1 J
bounty Parcel Identification No.(PIN) r "~
I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) t 22.Certification:
I7 '�. NS�' � 5,� W C �116 r
6.Is(are)the well(s) k ermanent or Temporary Signature of Certified Well Contractor ate
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Se or nNo 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: S SUBMITTAL INSTRUCTION
9.Total well depth below land surface: 00 (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@200'and 2@100') construction to the following: i
10.Static water level below top of casing: Ic (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"1,, 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �'1 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
,,per 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
(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
i
13a.Yield(gpm) Method of test: vl 24c.For Water Supply&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: 44 nL Amount: �Q � completion of well construction io.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