GW1-2022-03310_Well Construction - GW1_20220314

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
��1�,S � � 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
N[C C- 00k_ ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Beable
�i 1`l, FROM TO DIAMETER THICKNESS MATERIAL
` Q ft. 13 11. - I 1 c•in. 15D r C'
Company Name
16.INNER CASING OR TUBING eother al closed-loop)
2.Well Construction Permit#:1J l f a B FROM TO I 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) OF Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: I ft. o ft. r
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets K necessary)
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil rock type,grain size,etc.)
ft. LD s ft.
4.Date Well(s)Completed Well ID#1)29- 18 R ft.ft. ft.,3 sft. ;)
5a.Well Locati; � ft. ft.
C�Cl
Facility/Owner Name - Facility 1D#(if applicable)
ft. ft.
Physical Address,City,and Zip ft. ft.
'� 11.REMARKS
County Parcel Identification No.(PIN) �1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s) Permanent or OTemporary Si tore of Certified Well Contractor Date1y �
By igning this 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 wit 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 n explain the nature of the y 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
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: j SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: aq(D (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@100) construction to the following:
t
10.Static water level below top of casing: l (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:_1D (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
,n r above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Y F 1 R rz, construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) CS
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ..AA 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 1� 1 r2 24c.For Water Sunnly&Injection 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: 30 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016