GW1-2022-00302_Well Construction - GW1_20221222

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
l
1. ell Contractor Information:
14.WATER'ZONES
? FROM TO DESCRIPTION
Well Contractor Name ft.66 ft.
L1 (4 J ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased,welis)OR LINER if a Iicable)
FROM TO DIAMETER THICKNESS MATERIAL
in. D0040
Company Name 16.INNER CASING OR TUBING( ebthermal closed-loop)
2.Well Construction Permit# FROM TO DIAMETER ATERIAL
THICKNESS M
ft. ft. in.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)
ft. ft.3.Well Use(check well use): in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
'-Agricultural [Municipal/Public p ft. ft. in.
Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft. ft. in.
Industrial/Commercial oResidential Water Supply(shared) 18.GROUT
lrrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: to
Monitoring ORecovery ft. ft.
Injection Well:
Aquifer Recharge E3Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
i.-_ Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E]Stormwater Drainage
t Experimental Technology []Subsidence Control
Geothermal(Closed Loop) LOTracer 20:DRILLING LOG attach additional sheets if necessary)_
FROM TO DESCRIPTION color,hardness soilfrvek type,gmin size,etc.)
RGeothermal(Heating/Cooling Return) L-1 Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: Well ID# ft. ft. P:.'
5a.Well Location:
'S L ,;e A kh P I _ YT 2 2 2022
Facility/Owner Name !� �i Facility ID#(if applicable)
/ ft. ft. ^'� y� �+
yV4�
Physical Address,City,and Zip
21.REMARKS -
County Parcel Identification No.(PIN) '/
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
1-7 ( IQ 11 N 7yo6o '2y'` W 0; 1�
6.Is(are)the well(s) ermanent or Temporary Signature of Certified Well Contractor Date
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: try-,.Is, or DNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a
If this is a repair,fill out(mown 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: -(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@100D construction to the following:
10.Static water level below top of casing: �l (ft.) 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 Iniection Wells: In addition to sending the form to the address in 24a
Inv
also submit one copy of this form within 30 days of completion of well
12.Well construction method: d t �� 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) Method of test: A 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: �.e2Z�� 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