GW1-2022-01185_Well Construction - GW1_20220121

4 N.Wq, s e+ Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
\�)► m c 1 C' t6 Dio � A,5o n 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
l\I `4303 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Vl 1` I ►,1(x 1 © ft. in. P`/ ,'
Company Name h
e� ��n�� 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#:Wa=00 1r) FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Coun)4 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 Municipal/Public ft. ft.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
lndustrial/Cornmercial Residential Water Supply(shared)
18.GROUT
Ilri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft' t ft. `
Monitoring ®Recovery ft. ft. 1611061 1
I
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
E-JAquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) M Other(expl(ai�n�under#21 Remarks) ft. 3 1 ft. � C�
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
4.Date Well(s)Completed:.pa1Q� Well ID# a10aJtSUM7A0 31 ft. t it. R&d 5�44
t ft. /o f'„ ft. Blue, t�
Sa.Well Location: ��..11!!W
ft. ft.
5 C z
*Facility/Owiler
�Name Facility ID#(if applicable)
ft. ft.
p" e CSVVIr&n 1`Cii L`1�Z��1t�. mc, aml0f ft. ft.
nPhysical Address,City,and Zip �ry (�(� ft. ft.
4 l o l31 agg9,3000 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W ` _
to
6.Is(are)the well(s) Permanent or Temporary Si ture of Certified Well Contractor Date
777777������ By igning this farm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or No w'h 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 n 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: 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: CPO, (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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:9I)z I\( 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: Al
c 24c.For Water SuuDly&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