GW1-2022-01187_Well Construction - GW1_20220121

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: Print Farm
1.Well Contractor Information:
AyV I 0-5 _D M)d 14.WATER ZONES
Well Contractor Nam(e� FROM TO DESCRIP ON
N C.we
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
"IleFROM TO DIAMETER THICKNESS MATERIAL
ft. 1 ft. W in. 51)Q G
10 'IL
Company Name ^^��..�� ,l �c�� 16.INNER CAS G OR TUBINGo(g thermal closed-loop)
2.Well Construction Permit#: 1f OtW��L.k.�~[ 11-�Lf J FROM TO I 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 [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
hldustrial/Commercial Residential Water Supply(shared) 18.GROUT
Ilri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: t ft. I ft. _
1
Monitoring ®Recovery ft. ft. 1
Injection Well: ft. ft. 1
Aquifer Recharge nGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery ®Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets Hnecess
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explaci�n/ungd�eer�#21 Remarks) ft. 1 Ft.
4.Date Well(s)Completed.1_( `O Well ID# ft- s ft.
5a.WellLocation: ft. Q ft.
� • ft. ft.
Facility/Owner Name
p p ,��y �(/� Facility
ID#(if applicable) ft. ft.
?U eft W 1E l- U 0 1 r 1 FAR YJ 1 A _ IV C ft. ft.
Physical Address,City,and Zip ft. ft.
C 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:
c
N W _ ep
6.Is(are)the well(s) Permanent or Temporary e15ANCA*CO2C
d Well Contractor Date
s 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 .0100 or 1 SA 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: O�Q i (ft.) 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:
�[ 1
10.Static water level below top of casing: 0� (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: U (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: (`Y 1�Z l l� 14 rE 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
t
13a.Yield(gpm) Method of test: 117, 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 TeIIE6 Amount:S256 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