GW1-2023-02071_Well Construction - GW1_20230307

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Co tractor Information:
q 14.WATER ZONES I
FROM TO DESCRIPTTON
Well Contractor Name, k. fL
9�w�- ft fL
NC Well Contractor Certification Number rr�� f/1, 15.GUTERCASING.for multi cased wells OR LINER if u licable
J_ FROM TO DIAMETER TffiC[INFSS MATERIAL
Company Name 16.'INNER.CASINGOR'TUBIlVG eothecmal'closed-loo
2.Well Construction Permit#: , / / FROM TO DIAMETER TffiC1(rMs I MATERIAL
List all applicable well construction permits Ct.e.fIIC,County,State,Variance,etc.)
ft. ft. i-
ft. ft. I.3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM I TO DLAMETER SLOTSIZE I THICKNESS I MATERIAL
Agricultural [3Municipal/Pirblic ft. k in
Geothermal(Heating/Cooling Supply) F64dential Water Supply(single) ft, ft in
Industrial/Commercial E)Residential Water Supply(shared) 18.GROUT
Ini atlon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ff b ft eAft V11 i✓ D u m, 13 �3 S
Monitoring Recovery ft. ft
Injection Well: ft. ft.
Aquifer RechargeGroundwater Remediation 19.SAND/GRAVEL PACK if:a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test oStormwater Drainage ft ft
Experimental Technology } DSubsidence Control ft. ft
Geothermal(Closed Loop) OTracer 20.'DPMLING LOG.attach additional sheets.if necessa
RFROM TO DESCRIPTION color,hardness,softeck size etc
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) � ft.
. z `Y
4.Date Well(s)Completed: Well ID# ft. �—o fL fU t
ft. ft.
5a.Well Location:
t t ! k. ft.
)D trl �IJ��
Facility/Owner Name l Facility ID#(if applicable) tL
6 b l yy y.
Physical Address,City,and Zip ft. ft.
2 t
Me-Dot4eJl 1.REMARKS
Parcel Identification - if:""r;,s•.C"t
County -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) ��Jf 22.Certification:0,6 f N —?S,Z,(� l 6 3 w
Signature of Certified Well Contractor Date
6.Is(are)the well(s) rmanent or OTemporary
B3'signing this form,1 hereby terrify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or No with-75A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that u
Ifthis Is a repair,fill out known well construction information and explain the nature ofthe copy ojlhis record has been provided to the well owner.
repair under#21 remarks section or on the back oflhis 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 Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed.'Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 'J b 7 (ft-) 24a: For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lfdierent(exarpple-3@200"and 2 a@1001 construction to the following:
10.Static water level below top of casing: U/ b (fL) Division of Water Resources,Information Processing Unit,
If water level is above casing use"+'t 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection 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: Q11 r 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) '7' Method of test: a-1 j/ 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit Ione copy of this form within 30 days of
13b.Disinfection type: Amount: G Lt j completion of well construction to the county health department of the county
where constructed.
Farm GW-1 North Carolina Department 6f Environmental Quality-Division of Water Resources Revised 2-22-2016