GW1-2022-00323_Well Construction - GW1_20221222

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
�i.weu Contractor Informad : t
�li d GCrYYt - - - 14,1(rAT R ZONES 6
�pM TO DESCRIPTION
Well Contractor N2ama /} ft• ft' I
ti' ft.
NC Well Contractor CcrtiBeafioa Number wI 15r0Y1 PF,R-CAS .G'[or•inulti caged wells'OR cla s llMAT
` p� TO - DIAMETER THICtITfESS MATEAW.
ft.
Company Name 16,7NNE 'C.' INGORTi G- edtkermtil:cfosed-loo
.,•� 1/ FROM TO DiA11tETER THICKMS MATE It L
2.Well Construction Permit#: v�-� Et. i°'
List all applicable well construction permits(l.e.Wc,County,State,Variance,eta)
ft. ft. c !n.
3.Well Use(check well use): 1.. ft.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THfCtOVESS MATERIAL
M ci aUPablic fL ft. In
Agricultural p
GeoUletmal(Heating/Cooling Supply) @sidential Water Supply(single) ft, ft. iO
IndustriallCommercial 13Residential Water Supply(shared) 18..GR•U.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Lri scion D ft• d ft. e11 e d GCYe h S
Non-Water Supply Well:
Monitoring Recovery ft' ft.
Injection Well, ft. ft.
Aquifer Recharge [DGroundwater Remediation• 19.SANIFIGRAVEL PACK If;a licaHle
EMPLACEMENT METHOD
Aquifer Storage and Recovery,, Salinity Barrier FROM tr. TO ft MATERIAL
Aquifer Test `, [3StormwaterDrainage
Experimental Technology "h" Subsidence Control
MV
Geothermal(Closed Loop) OTracer M'D LIN LOG.atteclr ESCR PTIO sheet to ueeessa
FROM TO DESCRIPTION color,hardness aoWrock a[re eta
Geothermal Heatin Cooling Return) •Other(explain under#21 Remarks D { ft. ?r, L�
4.Date Well(s)Completed: 1=Well ED# go f � ajn J-t
ft. ft. i
5s.Well Location: ft, ft.
�G1G�L-01y a*a
Facility/Owner Name p Facility IDN(ifapplicable)
Yl �r J ft. fr• F r
5 n ft ft
Physical Adds ess,Ci ,an 21. ARKS
a_,fm Ya r
County Paroel Identification No.(PIN) ;
5b.Latitude and longitude In degrees/minutes/secondos or decimal degrees: 22.Certification:
(if wall field,one latflong is sufficient)
N _ W
o Signatur of Certified WeU Contractor Date
--6.Is(are)thewell(s)"ermanent__or Temporary•
ay signing this form,7 hereby cerrO that the wells)was(were)constructed to accordance .
7.Is this a repair to an existing well: ®Yes or Nc with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this Is a repair,Jill out known well construction Information nd explain the nature of the
copy oflhis record has been provided to the well owner.
repair under 921 remark;section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed=Loop'Gbothcrmal Wells having the stone construction details. You ipay also attach additional pages if necessary.
construction,only 1 GW-1 is needed,'Indicate TOTAL NUMBER of wells errnttrt•s'rAI.nvs I RUCTIONS
drilled:
9,Total well depth below land surface:, �vr/� (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
pop miritiple wells list all depths IfdtfJ•erenu fexarinple-3 a(�?00"and 1Q1001 construction to the following;
]0.Static water level below top of casing: (ft•) Division of WateriResources,Information Processing Unit,
1617 Mall Selivice Center,Raleigh,NC 27699-1617
If water level is above casing,use"+/
I1.Borehole diameter: `� (�•) 24b.For Injection WeUi: 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: r �V 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
Method of test: a'/ � 24c.For Water Suualy I&iInlaction Wells: In addition to sending the Form to
13s.Yield(gpm) t the addresses) above, also submit one copy of this form within 30 days of
Amount: G� S completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
Revised 2-22-2016
North Carolina Department ofEnvironmeatal Quality-Division of Watelr Resources
Farm OW-1 � .