GW1-2023-01410_Well Construction - GW1_20230208

Print Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
r1 14,WATER ZONES
•` N FROM TO DESCRIPTION
Well Contractor Name
NC Well Contractor Certification Number 15.OUTER CASING for multitased wells OR LINER if a licabk
I FROM TO UTAMETER THICKNESS MATERIAL
ft. k. b in. �2 t,t'
Company Name .I
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#• G� FROM I TO DIAMETER THICKNESS MATERIAL
list all applicable well construction permits(i e.171C,County,State,Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
PPY FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural mcipaVPublic ft. k. in.
Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) k• k• in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 k k' " f, v '`
Monitoring Recovery
Injection Well: k k.
Aquifer Recharge ©Groundwater Remediation L�C� j
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
�tormwaterDraina a
Aquifer Test [] g
Experimental Technology []Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil)ock type, rain size,etc.
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks) k k.
4.Date Well(s)Completed: ll ID# ft in
el
R'
Sa.Well Location: k. ft.
ft.
DY /LI Irk� ft.
ft.
Facifity/Ow Name — Facility ft.
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:
3s' N 7 gy7Z 1 W 1Z-ZL ��2
6.Is(are)the well(s)iDile"rmanent or Temporary i of Certified Well CoNtfractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or Q'V with 15A NCAC 02C A100 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: 'y SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 39 0 (B•) 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@1001) construction to the following:
10.Static water level below top of casing: (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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: APO O-10TW"34 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
13s.Yield(gpm)_ Method of test: ' i;..t.. �1 ht 24c•For Water Suouly&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- f CIL Ira 4: 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