GW1-2022-01627_Well Construction - GW1_20220208

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well `Contractor Information: � . r �
`�7 Ly —Oan 1 `d �.! 1 l 66*,pu 14.WATER ZONES
�pWell
Contractor Name FROM TO DESCRIPTION
ft. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER Lf a licable
c tV,t ¢ �IACI FROM I TO DIAMETER I THICKNESS MATERIAL.
ft. 1 ft. in. V C
Company Name �
16.INNER CASING OR TUB G eothermal closed-loo
2.Well Construction Permit#: 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. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [)Municipal/Public ft. ft. in.
( Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
! hadustdal/Commercial Residential Water Supply(shared) 18.GROUT
'11rriization FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 1 ft. � a i
Monitoring EIRecoVery ft. ft.
Injection Well:
ft, ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test n Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
typGeothenmal(Heating(Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/racka rain size etc.)
_
4.Date Well(s)Completed-G- . Well ID#UP7t°x 1 16-db q° ft. t ft.
sft. ft.
c A-n ai—STi;K—e-
52.iirell Locatio ;
• b
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Physical Address,City,and Zip 1` ft. ft.
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 W 1
6.Is(are)the weil(s) Permanent or ]Temporary Sigt ature of Certified Well Contractor Date
Jwit
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 5A NCAC 02C.0100 or I 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: 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:1 IXIU -(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdij/erent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 401 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
a above,also submit one copy of this form within 30 days of completion of well
aA
12.Well construction method: 1`,1 K F 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
13a.Yield(gpm) t Method of test:a te 1z 24c.For Water Supply&1111001011 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: a b�il-p,-6 Amount: 13® 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