GW1-2022-01934_Well Construction - GW1_20220224

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Informa'on: f
4
14::WATER ZONES
FROM TO DESCRIPTION
Well Contractor
cto N-�a,grme1 ft. 3 aft.
A ft. ft.
NC Well Contractor Certification Numper 15.OUTER CASING-(for multi cased;welis OR LINER if a` licable
!� a FROM TO D TER THICKNESS MATERIAL
fo P Q1 ft. ft. in, t l{ 11
Company Name vi V tl
�p fl F INNER CASING OR TUBING'eothcrmal dosed-ES
2.Well Construction Permit#: (r�ram' I FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) ft. tt. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well- 17.;SCREEN.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL_
i Agricultural Municipal/Public - tt. ft. — in:
Geothermal(Heating/Cooling Supply) gResidential Water Supply(single) ft. ft. in•
industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT TROD 6r AMOUNT
Non-Water Supply Well: 01 ft. ft.
keni
1.:Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge n Groundwater Remediation 19.'SAND/GRAVEL PACK ifa licable
Aquifer Storage and RecoveryISalinity Barrier FROM TO MATERIAL, EMPLACEMENT METHOD
i_.I Aquifer Test []Stonmwater Drainage
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG:attach-additional sheets if necess '
Geothermal(Heating/Cooling Return) r— Other(explain under#21 Remarks) FROM TO DFSCRIMTON color,hardness soil/rack type,grain sim eta
ft. ft.
4.Date Well(s)Completed: DL a "Z Well ID#
ft. fL
ft. ft.
Sa.Well Location:
�4L Sly-
Facflity/dwnerName Facility ID#(if applicable) ft. ft.
® ( 'e ft. ft. FEB 2
Physical Add ess,City,and Zip I tft. ft.
21.REMARKS
�aU1r�1�Lr
County Parcel identification No.(PIN) r'•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattiong is sufficient) 22.Certification'
• r
N W
6.Is(are)the well(s)dpermanent or Temporary Signatur of Certified ell Contractor Date
By signing this form,I hereby certify that the wr//(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or R(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
constmcti n,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: (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 cr 200'and 2@100') construction to the following:
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
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11.Borehole diameter: (in.) 24b.For Infection Wells: in addition to sending the form to the address in 24a
� r�� above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: /A 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 m o Method of test: �J� W 24c.For Water Supply&Inieet
(gP ) ion 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: Amount:=,U/ completion of well construction t!o the county health department of the county
=hO7 where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource's Revised 2-22-2016