GW1-2022-01541_Well Construction - GW1_20220120

1;l lull-/VIM
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well
Contractor Information:
1) 0 n Pop 14e, 14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name
2 g p r A
ft. ft.
NC Well Contractor Certification Number n 15.OUTER CASING for multi-cased wells OR:LINER it a licable
C !Q _o� POO �I`�I x N� /^ FROM TO DIAMETER THICKNESS MATERIAL
1 (/ W D tL Q ft. in. 0 r q
Company Name
16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#: FROM To I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Varl ke,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water,Supply Well: FROM SCREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft. in:
Industrial/Commcrcial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D tt. ft. it ft. r v-av,
Monitoring Recovery ft. ft.
Injection`Mll:
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
tt. ft.
Experimental Technology DSubsidence Control
RGeothermal(Closed Loop) DTracer 20.DRILLING LOG.attach additional sheets if necessary)
Geothermal(Heatin /Coolie Return) Other ex lain under#21 Remarks FROM TO DFSCRIPTION color hardness soilirock in si etc.
O tt. � ft. 12101
4.Date Well(s)Completed: (D y I Well ID# go ft.
5a.Well Location: 6 fL r7 ft. -S/q et irOG�
r Ara n t !� �� fL ft.
Facility/Owner Name Facility 1D# if a licable ft. ft
46 7 RL l l ro�� rA , gesso n
Physical ddress,City,and Zip
T��(�s�'A h G 21.REMARKS t.= . t t
County Parcel Identi cation No.(PIN) `'• 3t
e `j1 t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 22.Certification:
N W d4n
6.Is(are)the well(s)dPermanent or DTemporary Signature Certified Well'Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordmlce
7.Is this a repair to an existing well: Dyes or �No with 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 and 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
construct only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
ion,
drilled:t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdtfferent(example-3@2200'and 2 100) construction to the following:
10.Static water level below top of casing: D (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: Q j r r d Q ry construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ',1 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20. Method of test: b W 24c.For Water Sunvly&Inleci(tion Wells: In addition to sending the form to
LL the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: _ Amount: 2 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