GW1-2022-04014_Well Construction - GW1_20220422

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
,T6�Pr> 9`� FROM
WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft. S
�`^(J l� A' ft. �1 O ft. 6 Yn
NC Well Contractor Certificatio Number 15.OUTERCASING formuld a wells ORLINER fa Ilcable
�n I FR06f TO DIAMETER THICKNESS MATERIAL
Ci U q ft. ALI ft. In.
Company Name 16.INNER CA9I18G.OR TUBING eirthermal closed-loo
�i i ' ® FROM TO DIAMETER THIClaiEss MATERIAL
2.Well Canstinction Permit#: VJ �ftt. g, in.
List all applicable well construction permits(i.e.IAC,Counq•,State,Variance,etc.)
.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICIINESS MATERIAL
Agricultural unicipal/Public ft. it ►�•
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R ft. in
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. r /Q
Monitoring DRecovery ft. n' 2;—?e
IF
ction Well: ft. ft.
uifer Recharge Groundwater Remediation
19.9ANDlGRAVELI'ACK ;a Ilcable
uifer Storage and Recovery [!Salinity Barrier FROM TO MATERIAL, EMPLACEM1IENTMETHOD
uifer Test oStorn'twater Drainage ft ft.
perimental Technology 13Subsidence Control fL ft.
othermal(Closed Loop) Tracer 20.DRILLING LOG attach additionalsheetss If necessary
FROM TO DESCRH'TION color harda saWrock a ins etc
othermal(Heating/Cooling4�RetUM) Other(explain under#21 Remarks) ft 7-0 ft. Cl6
VI
4.Date Well(s)Completed: J a Well ID# 6( -1 D ft' 100 ft ytc
5a.Well Location: ft. ` 00 ft. TQYi r pt
uo � d-. tl. ft
Facilityy/� nerName r� Facility lD#}(ifapplicable) R• ft.
Physical'Address,City,and bp •'� t ft. ft. APR r
_ Wake 1 ! q�41 ty 1 0 1 0 2L REMARKS
County Parcel Identification No.(PIN)
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 Signal F
of Certifi ell Contractor Date
By.signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or dNo with 15A NCAC 02C.0100 or 15A PICAC 02C.0200 Well Constntction Standards and drat a
Ifiks is a repair,fill out knoum 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
construction,only i 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: o (ft.) 24a.For All-Well : Submit this farm within 30 days of completion of well
For multiple ivells list all depths ifdderent(example-3@200'and 2Q1007 construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
Ifwaterlevel is above casing,use"+" 1617 Mail SeiMce Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: a I tr co a construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) If
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)_ 0 Method of test:. )0 24c.For Water Suvyly&Infection Wells: In addition to sending the form to
JJ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: l 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