GW1--03404_Well Construction - GW1_20230517

WELL CONSTRUCTION RECORD(GW-1). For Intemal Use Only:
1.Well Contraetoj)��tion:
14WATERZONES
FROM TO DESCRIPTION
Well CoutrsctorName
a y2 ft ft
fc ft
NC Well CO=W,.CM-0 Number 15;OUTER,C4
SIN6 for wells OR LINER IfS FROM TO DUM THFC[Q�SS MAAe
TERIAL
ft d ft m /'VC
Company Name `
16:�.INNEIY,CASIl�iG•[3R.TfTBfNO:
2.Well Construction Permit#: FROM I T9 I nlAMsrEx I THICtQVF55 I MATERwL
List all applicable well construction perm (t.its e.UIG Carroty,State,Yanmxe,etc) 1 D
3.Well Use(ebeck well use): i
ft ft m
kAgricultural
ter Supply Well 37:SCREEN`
Ppl FROM DIAMETER SLOTSIZE THICKNESS MATERIAL
13Mtmi paUPubliC o ft & im
eothermal(Heating�Cooling Supply) identiai Water Supply(single) R ft in.
ndustial/Commercial [3Residential Water Supply(shared) A&GROIIT:rI ionI FROM I TO MATERIAL EMPLACEMENT METHOD AAMOUNT
gat
Pion-water supply Rt� f< l) & v D U 3
Monitoring ORecovey It. ft
Injection Wen:
ft. ft
Aquifer Recharge DGroundwater Remediation
{'� 19..SAND/GRIeYEL'PACH Ie .
i
Aquifer Storage and Recovery rk Salinity Barrier FROM TO. MATERIAL I EMPLACEMENT METHOD
Aquifer Test' Stormwatrr ft *!f
Aq 1)IarnaExperimental Technology 13Subsidence Corrtrol "< fc.
Geothermal(Closed Loop) Tracer 28 DRH&H4G:LOG.a=.1La IdMur also efit _
Geothermal(Heating/Cooling ) Other( lain under i121 Remarks) FROM TO DESCRIPTION color,hardnt"s sae,eta
ft. ft. J
r
4.Date Well(s)Completed:-� t7 Well ID# �� c ft (/1
C_
5 Well Location: ft
r t ft ft.
y71 ie/IiC' l� -`
-faPP ft fL .
Facility/Owner Name Facility
II)#(t )
3S 16 ft fG
Physical dam,Cirf,and Tap fL ft MAY 1
.:MRE114AM -
County Parcel Idemificaaon No.(PIN)
5b.Latitude and longitude in degrees/minates/seconds or decimal degrees:
(ifwell field,one lat/tong is sufficient) 22.Certification:
N W d 2
6.Ware)the wells) Permanent or 13Temporary Signatmc of Certified Well Contractor f Date
By signing this form,I hereby cenVy zhaz the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or io with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Sra rdards and that a
If this is a repair,fill our kwwn well canstt urtton it formation mud explain the nature of the copy of this record has been provided to the well owner.
repair render 921 remarks section or on the back of this form. 23.Site diagram or additional well details:
S.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 Tndicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
filled" SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: D A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple we&Ast aU depths if abf j-epew(mo ple-3(a)200'and 2@1003 construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing use••+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in) 24b.For Injection Wells: In addition to sending the form to the address in 24a
u f above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: �� construction to the following:
(i.e.augc,rotary,cable,direct push,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
132.Yield(gpm) Method of test: - 24c.For Water Sun&&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 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