GW1-2022-00196_Well Construction - GW1_20221216

�WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: Print Form
1.Well Contractor Information:
0 "I 14.WATER ZONES f
We C-;lActor Name _ _ FROM TO DESCRIPTION
0"
& ft
NC Well Contractor Certificati N her r r� n
2l'27 15.OUTER CASING for multi-cased wells OR LINER if a 6rable
FROM TO DIAMETER THICKNESS MATERIAL
Company Name lrtful f i"W.'=i...^^: 7ti v fk t ft. / 1/ in
rl• V
7 l� 16.INNER CASING OR TUBING(geothermal closed-loo
2,Well Construction Permit#: tJ v ! FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft- & m.
3.Well Use(check well use): ft ft in-
Water Supply Well: 17.SCREEN
FROM TO DIAME M SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public 0 & &
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft ft in.
Industrial/Commercial Residential Water Supply(shared)
1S.GROUT
71Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O & ft
Monitoring Recovery ft. ft.
Injection Well:
ft ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft ft
Experimental Technology []Subsidence Control fL ft.
BGeothermal(Closed Loop) [DTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPMON color,bardn=%soWrock WM grain size,etc.)
ft ft. 6_
4.Date Well(s)Completed: Well ID# ft. ft f C
5a.Well Location: ft ft Sd)
r l,L a� A ft ft
Facility/Ow//nerName Facility ID#(ifappllicable) ft ft
b C6 9u Y tf 1. w If G Drk')t -Z ft Q ft
Physical Address,City,and Zip / ft. R
7 6- s6- C�a�r 21.RE1V(ARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s) ermauent or ®ITemporary cure Certi d We Con clot Date
signing this form,1 her b certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or DPdt- with 15A NCAC 02C.0100 r 15A NCAC 02C.0200 Well Construction Standards and that a
1f 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 Ul 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: (fti) 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:
�J 1
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
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�foim within 30 days of completion of well
12.Well construction method: 11O a4l 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
A
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injectiod 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: / r k Amount S completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016