GW1-2022-01845_Well Construction - GW1_20220216

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Con actor Information: ,{�� to .� ^
5 14.WATER ZONES �
Well Contractor Name FROM TO DESCRIPTION
r t rt. ft. C„
17
NC Well Contractor Certification Number 15.OUTER CASING for could-cased wells OR LINER if a licable
I,, 1„^�^ FROM TO DIAMETER THICKNESS MATERIAL
`�(1 It. ft. in. Sc, (�CI C,
Company Name 16.INNER CASING OR T ING Igeothermal closed-loop)
2.Well Construction Permit#: FROM TO DIA TER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County.State, Variance,etc.) ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0 icipaUPublic ft. j� ft. A In.]
_ Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
R
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft. v�
_ Monitoring DRecovcly ft. ft.
Injection Well:
ft. ft.
-- Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
Aquifer Storage d Recove Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer TestIStormwa[er Drainage ft. tt. r
" Experimental T ology QlSubsidence Control
RGeothermal
Geothemi osed Loop) Tracer 20.DRII LING LOG attach additional sheets if necessa(Heating/Coo Conlin Return)
er(explain under#21 Remarks) FROM TO DESCRIPTION color,n n soiltrock a in size,etc.
ft. ft. J Uf
4.Date Well(s)Completed:; Well ID# ft. ft.
5a.Well Location, A ft. ft f✓
,92 C, ft. tt. s
(� t
Facility/Owner Name Facility ID#(if applicable) ft. ft.
01A10,La
Physical Address,City,Lnd Zip
21.REMARKS
Countyty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifieatio
N W
6.Is(are)the well(s) ` ermanent or Temporary SignatuKe afCcrtified Well Contractor Date
�--�� By signing this(arm,I hereby cert�,that the ttvIl/s)was(were)constructed in accordance
L'f
7.Is this a repair to an existing well: OYes or r"' with 15A NCAC 01C.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 an the back of ihis 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: .7 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3Q200''nand 2Q100� construction to the following:
10.Static water level below top of casing: d / UP Division of Water Resources,Information Processing Unit,
lfwater level is above casing.use"+/ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: in.t1�
(� ) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Q above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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) Method of test: ✓° 24c.For Water Supply&Iniection 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: f-'n— 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 Resource's Revised 2-22-2016