GW1-2022-01943_Well Construction - GW1_20220224

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractors Information:
FROM TO DESCRIPTION
Well Contractor Name
aa'd( a ft. ". o
%
NC Well Contractor Certification Number ,,1 TJ2? C <fot innitf led ri ell R ft_ Ie
V/ K R 6 a�� E W�I/ l O FROM TO DIAMETER THICKNESS MATERIAL
it ft. ( In. i sl d p
Company Name INN 1t;GA5 G;t31t1^I3B1if±ll: r alitlut o /a'.
2.Well Construction Permit#: fTD D00 635 FROM I TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits 6.e.UIC,Count),,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft it. in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL "
_-OAgricultural _ _- ---- —--O//Mtmicipal/Public- — - tt — — ft. in.
OGeothermal(Heating/Cooling Supply) DlResidential Water Supply(single) ft, ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 77777= 4,ry;
131frigation ❑Wells>100,000 GPD FROM TO MATERIAL 1_ EMPLACEMENT METHOD&AMOUNT
1 Non-Water Supply Well: 0 ft; 0 ft en ode ra
❑Monitoring ❑Recovery ft. ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
DAquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD y
❑Aquifer Test ❑Stotmwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft tt.
❑Geothermal(Closed Loop) ❑Tracer
FROM TO DESCRHMON color,hardness,ealUrock type,grain slue etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) b ft b ft. G!a I
4.Date Well(s)Completed: - as Well ID# sa ft. /d,d ft' (fir!
5a.Well Location: �D d fL . rl
de-
ft. ft.
luvnes is n
Facility/Owner Name Facility ID#(if applicable) ft ft ^.
9' 71 A Is n rr� f Ca64 114 NO L 81b tt. ft.
Physical Address,City,and Zip
County Parcel Identification No.(PIN) n a y <-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
L/ N W �a�► a- �- a�-
6.Is(are)the well(s): (9Yermanent or ❑Temporary Si f Certified U Contractor Date
By signing this form.I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or ONO15A NCAC 01C.0100 or]SA NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the 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 t"o provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 'S 6 (ft•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: p (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use'
24b.For Injection Wells: Copy to DWR,Underground hnection Control(TUC)
11.Borehole diameter: (in•) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Q 1 r 24c.For Water Sapgly and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department ofthe county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
p Petmtt Program,1611 MSC,Raleigh NC 27699-1611
13a.Yield(gpm) 6 Method of test• I P W
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018