GW1-2022-01186_Well Construction - GW1_20220121

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: Print Form
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
NC/+��(n
I% C ;�7L+ ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mind-eased wells OR LINER if a licable
FROM TO DIAMETER TffiCKNESS MATERIAL
tonCompany Name
0 ft. 1 ft. t a$' in. $ L
n 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#W& f G�C�L)L/&,P FROM TO DIAMETER THICKNESS I 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 MunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft.
hrdustrial/Commercial JAResidential Water Supply(shared) 18.GROUT
Ir ri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6
ft. ft. RmAland e _
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets If necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM I To DESCRIPTION(color,hardness,soft/rack type,grain size,etc.)
��f�l���nr�/�f/ �f ft. ( ft.
4.Date Well(s)Completed:ta�1 Well ID#f�You.�CAM 7�OOt t ft. t ft.
5a.Well Location: fl- ft. R
ft. ft.
vFacility/Owner Name Q n^ e) Facility ID#(if applicable) ft. ft.
�� �� y� �,n^`tt CA
(� CJ{'G,.w�O� �+ ft. ft.
J A ym bMm l A 1` `L1 L M�. n- i r- ft. ft.
Physical
Address,City,and Zip
a uylee- 451bM01U3b4&= 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
s +l
�{ N Jts
9118-a l
6.Is(are)the well(s)#XJ Permanent or Temporary une of Ccrtified Well Contractor Date
7777'''�CCC ning this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repairto anexistingwell• ®Yes or No 5A 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 copyof 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
consttuctiorl 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: w (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 2Q100') construction to the following:
t
10.Static water level below top of casing: 1 W (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
Al above,also submit one copy of this form within 30 days of completion of well
W
12.Well construction method: R tt RC�LI�4�U 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
r
13a.Yield(gpm) clo Method of test: 24c.For Water Supply&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: t 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