GW1-2022-01196_Well Construction - GW1_20220121

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor
fo
ctor Information: '
lAt 1'1 Es 1 J A in 1�l W L 1��n 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
IV C VY C 4303
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wens OR LINER if a livable
c r��••- ( (f s FROM TO DIAMETER THICKNESS MATERIAL
U.ft. PY in. Ir -?Y
Company Name ',r^ /��� n 16.INNER CASING OR TUBING eothermat closed-loop)
2.Well Construction Permit#:W/�DW 006,2 9 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.
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
lrri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. t ft.
Monitoring 1311ecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery n Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft. ft.
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) nTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soii/mck e, ain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. I ft. Z
4.Date Well(s)Completed:G-02:9L Well ID#W 9h2-6 0- 9A 3I ft. LDO t ft. Deco
5a.Well Location:
Facility/Own r Name r Facility ID#(if applicable)
-90 Jnn
(�`1 Itll ) re SL7� 5-Y ft.
�RIV� 1
ft.
Physical
r Address,City,and Zip I I
M f� (�, ft. ft.
45l o^ C691 -35 00 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 W11f5ANCACO2C.0100
�/►MDD `�O Vri A 11'�6.Is(are)the well(s) Permanent or Temporary ure of Certified Weil Contractor Date
ning 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 or 15ANCACO2C.0200 Well Construction Standards andthata
If this is a repair,fill out known well construction information nd 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: r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 41D( (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: `-k}I (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: �yl--�f) construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) 1
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: Ul L 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: ?gill& Amount:36 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016