GW1-2022-01628_Well Construction - GW1_20220208

PrintForm
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
N CW C 430- ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for moth cased weds OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Lod w e L.L(Alz N n iA ft. 41Ift. � o:�,5 in. r1 PYC
Company Name 16.INNER CASING OR TUBING eother at closed400
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft.
3.Well Use(check well use): ft.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
h'ri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. t ft. Q
Monitoring Recovery ft.
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SANDIGRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test nStormwater Drainage ft. ft.
Experimental Technology [3 Subsidence Control ft. ft.
Geothermal(Closed Loop) [:]Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
e�^� ft. t ft.
Ea Nk
4.Date Well(s)Completed: Up-.'U Well ID# ft. Oft' R� t
5a.Well Location: 1'el
r _ �( l
1 C-r "i-t
Facility/Owner Name Facility ID#(if applparliiccablep) ft. ft.
�c� Mir©it I i I M I-I �"I D I�
Physical Address,City,and Zip �--- I
Un z,`Ke- 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification: '� ��
N W (y
6.Is(are)the well(s)BJliPermanent or Temporary Sig ture of Certified Well Contractor Date
T� By igning this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or No 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 a d 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
t
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 if different(example-3@200'and 2@1001 construction to the following:
t
10.Static water level below top of casing: (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: hi addition to sending the form to the address in 24a
I�' �� �,, above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Yt ' l 1_4r+ 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: C c 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: '0e,NJ(iTs 24c.For Water Supply&Iniection Wells: In addition to sending the form to
VhD ( the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 141 Amount: �� 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