GW1-2022-00157_Well Construction - GW1_20221219

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
SE �i' /3,7,ck1s 17/`mo1 7(ZZ 14.WATER ZONES �
Well Contractor Name FROM TO DESCRIPTION
ft IQ ft.
� )L,4
N�Well Contractor Certification Number -S L 1,9 ft „* Ili`
rt�l/! 15.OUTER CASING for mu1,ti-cased wells OR LINER if a licable
I_ J FROM TO DIAMETER THICKNESS MATER AL
Company Name f� / 6 ft ft f in C
1 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: t� FROM I TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,eta) ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DWMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public U ft. ft. in.
Geothermal(Heating/Cooling Supply) — esidential Water Supply(single) ft. ft.
— Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. p�0 ft 3*?75_tzL7 QU
Monitoring DRecovery & ft
Injection Well:
ft. ft.
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO 11fATERiAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage fL ft.
:)Experimental Technology Subsidence Control ft. &
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIfION color,hardness,soiuruck type.grain size,etc
4.Date Well(s)Completed: V131,?� Well ID# &Mfz ft r'ol✓ eia9L /
5a Well Location: r.,�; `W�.y.:, Fa%sa.;r ft ft d /
J��e s /� /Sam ft ft. /204
Facility/hvnerNeme �E if p p hf'.aW 2_ ® ft d—
/'
ft. r-e
ra�Le
l,na
Physical Address,City,and Zip Jt.`e+C l R' D'
la ad L& 21.REMARKS
Ceunty Parcel Identification No.(PIN)
I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
n
N W
6.Is(are)the wel(s)! ermament or QlTemporary St tore o erti a ell ontrac r Dat
� y signing this form,1 hereby rt�that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or � with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of die 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: 00 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:
I
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
.tf �
11.Borehole diameter: (in.) 24b.For Iniection 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: 71- construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
1
Division of Water Resources,!Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: . ) 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �� d Method of test: V W 24c.For Water Supply&Iniection 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. I
Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016