GW1-2022-03566_Well Construction - GW1_20220328

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WELL CONSTRUCTION RECORD(GW-1) or Internal Use Only:
1.Well Contractor Information: t,t
\ ){Qm� Dw cl 1 1s 11.WATER ZONES
Well Contractor Name F 10M TO DESCRIPTION
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NC Well Contractor Certification Number 1 .OUTER
R; e CASING LINER if
T acable
O OM IKE
MATERIAL
r ft. t ft. in.
Company Name
1 .INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: OM 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: 11.SCREEN
F OM I TO DIAMETER I SLOT SIZE I THICKNESS J MATERIAL
Agricultural nMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
hldustrial/Commercial NResidential Water Supply(shared) 18j GROUT
Irri atiori MOM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 1 ft.
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19 SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test 13 Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
ft. t ft.
,rr r ft. 1 ft.
4.Date Well(s)Completed:' — `t' Well ID#
5a.`Well Location: 39tft, ft.
©c bM6 I
ft. ft.
Facility/Owner
�Name
n /Facillity ID#((if applicable) �s ft. ft.
MY 1 l`e-1 1`l l/�� d D 7!1 It. ft.
P sical Address,City,and Zip ft. ft.
(_,gyUUm 21. MARKS
County l Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) t2aification•
N Wr 1
3-a4-aa
6.Is(are)the well(s) Permanent or Temporary of Certified Well Contractor Date
TTTCCC this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existingwell• ®Yes or No NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information n explain the nature of theis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthisform. diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same 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 tion details. You may also attach additional pages ifnecessary.
drilled: TTAL INSTRUCTIONS
9.Total well depth below land surface: t')1A (ft.) 24a.r
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') consthe following:
1
10.Static water level below top of casing: (ft.) ion of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: � (in.) 24b. tion Wells: In addition to sending the form to the address in 24a
0 �) abov,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Yt (L�1 cons ction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
D 'sion of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
r
13a.Yield(gpm) �0� Method of test I(� 24c. or Water Su 1 &Injection Wells: In addition to sending the form to
the a dress(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 30 comp etion of well construction to the county health department of the county
when constructed.
Form GW-1 North Carolina Department ofEnvironmental Qua'ty-Division of Water Resources Revised 2-22-2016