GW1-2022-04018_Well Construction - GW1_20220422

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
f.VVeH Contractor Information:
f
ld:WATER ZONES
Well Name FROM TO I DESCRIPTION
ft,. ft.
14C Well Contractor Cc ifi tion Number I �/J� 1S:.OUTER CASING for:multi cased wells;OR'LINER:If a 'licabie
C 1 v 1 FROM TO DIMiETER THICKNESS MATERIAL
!i 1 �JU ft. ft. in.
Company Name
��� 1 ��77 ,q{/�� 16.INNER CASING OR:TUBING 'eotherinal closed-loo
2.Well Construction Permit#: t/ 3 —v 9.) FROM TO I DIAMETER I THICKNESS bATERIAL
List all applicable uvIl construction permits rz.e.UIC,Count),,State,Variance,etc.J ft, dgr ft. in.
3.Well Use(check well use): ft. ft. in.
77:'SCREEN -
Water Supply Well: , . . ..
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public ft. .
Geothermal(Heating/Cooling Supply) ,Residential ft Water Supply(single) ft. ft. in.
Industrial/Commercial E311esidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT NOD&ADfOUNT
Non-Water Supply Well: ft.
Monitoring Recovery ft. ft. f
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery �' 8alini Barrier 19.SANDIGRAVEliPACK'ifa fiealik ;
FJ ty FROM TO MATERIAL EMPLACEMENTRiF,THOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRI.L LOG attach additional sheets if necess
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIMON color,hardncs soiVrock gain si etc.)
ft. ft.
4.Date Well(s)Completed: Well ID# tt. ft.
5aa..AWellpLo �tion: f g p�^ �I ft. ft.
a V��L�1 f`'r'�'`i�l io n ft. ft.
Facility/Owner Name'y�n �- Facility ID#(if applicable) C ft. ft.
Physical Address,City,and Zip ft. ft.
Q � 21-REMARKS" .. i r. l t 1 r oY 1 ^7__
County Parcel Identification No.(PIN) a e
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: F °
(if well field,one lat/long is sufficient) 22.Cer' /
N W ,' 3
6.Is(are)the well(s)oPermanent or Temporary rc o ificd yell Contractor Date
Bp 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 E3No 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:
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:- SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 2d (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+^_ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection 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:
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: C 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: J��W 24c.For Water Supply&Iniection Wells: In addition to sending the form to
ry ii the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: ! 1 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