GW1-2022-01169_Well Construction - GW1_20220104

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
�AM T, ,eC Ltd i t5e((l 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
earn l'�/� y�-• ft. 4ftt
Mr �'LCJC]t ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-Cased wells OR LINER if applicable)
c r FROM TO DIAMETER THICKNESS MATERIAL
Na 1 ® ft' ft. Wit`
Company Name r 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#:& SZI / 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
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public % ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) g• ft. in.
Industrial/Commercial Residential Water Supply(shared) 1S.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. 1 ft. R
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test n Stormwater Drainage ft. I ft
Experimental Technology Subsidence Control ft. I ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heatin Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sire,etc.)
ftel q If ft.
4.Date Well(s)Completed: _ Well ID# 'it 'f B�� ft. t ft.
ft. ft.
Sa.Well Location:
96tt.
Q � FacilityI ID#(if applicable)
ft.Faciiliitty/OwnerName ft.
r T ' - WVCt
ft. ft.
Physical Address,City,and Zip ft. ft.
,��ca��"tg®�cI L��I,� 2L REMARxs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) j2. ertification: .
N ta��a�6.Is(are)the well(s) Permanent or Temporary tore of Certified well Contractor Date
�{ gning this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or No 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 nd 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
t
9.Total well depth below land surface: ob fo (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:
1
10.Static water level below top of casing: Division of Water Resources,Information Processing Unit,
If water level is above casing,used'"n^+" 1617 Mail Service Center,Raleigh,NC 276994617 La
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: 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: 1 tZ 24c.For Water Sunnly&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 P 1pp[� Amount: Cg® __ 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