GW1-2022-01650_Well Construction - GW1_20220215

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
/1 /t��7 ft. ft.
Lklb J
NC Well ttContractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if applicable)
1 c c FROM TO DIAMETER THICKNESS MATERIAL
L 0 ft l ft. 26 in. Y C_
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
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.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. t ft. •
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK fif applicable)
Aquifer Storage and Recovery ®Salinity Barrier FROM TO MATERIAL I MPLACEMENT METHOD
Aquifer Test ®Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) ®Tracer 20.DRILLING LOG attach additional sheets if necess
FROM TO DESC PTION(color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) rl�1 Other(explain under#21 Remarks) 0 ft. t n t ft. C� C—C
4.Date Well(s)Completed:r l7—d'o� Well ID# ft. la,
ft.
ft,
5a.Well Location: LAUD
ft, c
ft. ft.
Facility/Owner Name Facility ID#(if applicable) R• ft.
� c��c;`M. Lmo t Rl,�jel�vs��P rt c_
Physical Address,City,and Zip
r`,n� 21.REMARKS
lCoountty� I Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) *i15A
ation:
a a
6.Is(are)the well(s) Permanent or Temporary Certified Well Contractor Date
op is 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 AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information n explain the nature oftheecord 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: b lD (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:
10.Static water level below top of casing: l J (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,/usee,"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: UJ (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
c above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: j 1 l�� �Z construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)� i
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 c 24c.For Water SuDiv&Iniection Wells: hi addition to sending the form to
�� �� �� `� uthe address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:l Amount: -3b 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