GW1-2022-03308_Well Construction - GW1_20220314

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
�J 1 I S 0 n 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
ft. ft.
4 30
NC Well Contractor Certification Number 15,OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
ft. &oa5, in. 5 RaI pvc-
Company Name
�Or1 (®p 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit# C ( 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 icipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) i Residential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
/ t
Non-Water Supply Well: 6 ft. ft.
Monitoring DRecovery
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soillrock e, rain size,etc.)
Geothermal(Heating/Cooling Return) ! Other(explain under#21 Remarks) 0 ft. ft. e� G'4
4.Date Well(s)Completed: n iL3o Well ID# ft• g lao v e
5a.Well Location: 57 ft. o ft. k?eC0MPO,5e.J•
oe Peso
n a v ft. -as- ft. I V e S +-,e
Facility/Owner Name Facility ID#(if applicable) D-s- ft. ? ft. 2t_0,;?Po5•e d S I
7al UI I FCC Cvrte rU Motohy 4A)c 1-"06 r5c6 ft. It' IuC I444
Physical Address,City,and Zip ft. ft.
o 'l crQ�nK 21.REMARKS
County 1"C Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22Mon: ° (,
6.Is(are)the well(s)`_ ermanent or Temporary
Sig of Certified Well Contractor Date
signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or U140 , 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:
S.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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: l U (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@2200'and 2@100') construction to the following:,(
10.Static water level below top of casing: " 1 0 (ft.) Division of Water Resources,Information Processing Unit,
If water Ievel is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
^. ,q� _r _ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: /`t t r7�tf 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) L Method of test: fy 1 r 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
All.Disinfection type: 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