GW1-2022-01161_Well Construction - GW1_20220107

Print Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well
`Contractor Information:
I 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
N cWc Q48 q ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
�� 1 1 �V1 FROM TO DIAMETER THICKNESS MATERIAL
ft. I rt. in. YG
Company Name 16.INNER CASING OR TUDING(geothermal closed-loa
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ]Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
hrdustrial/Commercial 9Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring EIRecovery
Injection Well: ft. ft.
Aquifer Recharge ']Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery ]Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ]Stormwater Drainage
" Experimental Technology ]Subsidence Control
Geothermal(Closed Loop) ]Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soft/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. I tt.
AA
4.Date Well(s)Completed:I a`U� Well ID#
ft.5a.Well Location: ft.
ft. ft.
Facility/O r Name ► y-1 {►/�Facility ID#(if applicable)
Physical Address,City,and Zip
21.REMARKS
County Y2 Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the well( Permanent or ]Temporary Si
re of erti£ied Well Contractor Date
ng this form,I hereby cert�that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ]Yes or No A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information n explain the nature of the 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: I 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-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: �n (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 Injection 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: 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) Method of test: F} 24c.For Water Supply&Injection Wells: In addition to sending the form to
11IC 1V the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: +9 Amount: C7d 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