GW1-2023-01966_Well Construction - GW1_20230227

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
t h ��! Y 14.WATER ZONES
rr/IIs O
FROM TO DPSCRIPI7ON
Well Contractor Nameft. tt.
NC Well Contractor Certification Number 15.OUTER CASING(for mold-cased wells)OR LINER if a liable)
h'RO�I TO DIAMETER �HICKNF.SS MATERIAL
ft. in. - r(?
Company Name 16.INNER CASING OR TUBING thermal closed-loop)
2.Well Construction Permit#: %SCREEN
TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i e.111C,County,State,Variance,etc.) ft. in.
ft. in.
3.Well Use(check well use):
Water Supply Well:
pp Y TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Q iclpal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. in.
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
[m ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply 11 ell: D' �an R'
Monitoring QRecovery
Injection Well:
Aquifer Recharge EJ Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test oStotmwater Drainage
Experimental Technology [:)Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soilhnck type,grain she,etc.
Geothermal(Heating/CoolingReturn) Other(explain under#21 Rcniurks) ft. et.
4.Date Well(s)Completed: — Well ID# ft. et.
ft. ft.
5a.Well tlon:
(�� ft. t
1Xl,f,f�c �►nc�r la S�nbv�sen
Faciilliity/Owner Name Facility ID#(if applicable) ft. ft' 1;,^r3 :+ift Lria
ft. ft.
Physical Address,City,and Zip
21.REMARKS _
�,mty Parcel Identification No.(PIN)
Qa
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) t� 22.Certification: J
36607 / 564 N a �-�'b 5�/I W
6.Is(are)the well(s) errmanent or E3T nary Signat of Certified Well Contractor Date
By signing this form,I hereby certify that tl we11(s)was(were)constructed in accordance
7.Is this a repair to an existing well: es or [3No with 15A NCAC 02C.0100 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: 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-3Q200'raQand 2 100D construction to the following:
10.Static water level below top of casing: �lan) (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: `f (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
l above, also submit one copy of this form within 30 days of completion of well
12.Well construction method:r f'1l(/f�l 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: p 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: r 24c.For Water SaaDly&Injection 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: (n U 11 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