GW1-2022-01264_Well Construction - GW1_20220112

WELL CONSTRUCTION RECORD(GW-1). For Internal Use Only:
1.Well Contra e Information:
l/r a 14WATERZONES f
FROM TO DESCRnrMN
Well Contractor Name R ©R `
NC Well Contractor C umber
I&OUTER.c�s1NG for>fl . OR Ll NER>f
/ FROM TO DIAMETER THIC[Q�SS MATERIAL
CompmyName / 16-DRIER. AR.TiJ81N(r:
2.Well Construction Permit#: =� U 0 L L FROM TO DIAMETER I TIUCKNIMS MATERIAL
List all applicable well construction permits(14 U1G Cowry,State,Variance,etc.) ft R. in.
3.Well Use(check well use): fL ft in.
k
ter Supply Well: F SCREENFROM TO DIAMETER SLOT SIZE '[iiiCkNESS MATERIAL
gricultural DMunic lic 0 & p -fy ;a eothermal(Heating(Cooling Supply) idential Water Supply(sigle) ft RidusttiaUCommercial DResidential Water Supply(shared) GROUT
Irrigation FROM MATERIAL EMPLACEMENT MErHOD&AMOUNT
Non-Water Supply Wen: R- R- d e1, T
Monitoring Recovery ft &
Injection Wen:
R ft
Aquifer Recharge Groundwater Remediation
19..SAND/GRMV.XL`PAC& le
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test' DStormwater Drainage D
Experimental Technology [Subsidence Control ft
Geothermal(Closed Loop) DTmeer 2D IHtII.LII!FG.1 G.attach a wdendApeeig
FROM To- D N color,hs dress,smilrock sae,err.
Geothmmal eatin Cool' ) Other( lain under#21 Remarks OL
R p &
4.Date Well(s)Completed: U a Well LD## & & B�
5a.W I Location: ft R
i
eA
R ft .
Facility/C+wnerName J Facility ID#(ifapplicable) R te
ft R
Physical . dress,City, Zip ft tt
l 21:REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minates/seconds or decimal degrees:
(ifwellfieid ox Wong issufficient) 22.Certif.cation:
w 2
6.Is(are)the well(s) Permanent or Temporary o S*mattl of ed Well Contractors pate
By signing this form,I hereby eerrtfyithat the well(s)was(were)constructed m occordame
7.Is this a repair to an ei isting wen: DYes or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Stmrdards and Thai a
1f this is a repair,JtH out!mown well construction Mforniation and explain the nature of the -P1•of this rewrd has been provided to the well owner.
repair under 921 rem axis section or on the back of this form. 23.Site diagram or additional teell details:
S.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: f SUBMITTAL INSTRUCTIONS
t�-S
9.Total well depth below land surface: (fL) 242. For All Wens: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdti ferent(a mmple-3®200•and 2@1001 construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
lfwaer level is above casing use"+ 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: �� /�G� above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,disco push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Matz Service' Center,Raleigh,NC 27699-1636
132.Yield(gpm) 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: l Amount: completion of well construction to the county health department of the country
where constructed.
I
Form GW-1 North CarolinaDepasnn Department Environmental Quality-Division of Water Resources Revised 2-22-2016