GW1-2022-04045_Well Construction - GW1_20220422

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Informlatiion:
14.WATER:ZONES
Well Contraclor45U
Namee FROM TO �t DESCRIPTION
NC Well Contractor Certification Number 15,:OUTER CASING.for multi casedwcils OR LINER fCn "livable
eitay c
FROM TO DIAMETER THICKNESS MATERIAL
` ) ft. f'I,2- ft- in. , !O d A
Company Name .. _ 16.INNER CASING.OR'TUBING 'eothermal.Aosedaoo
2.Well Construction Permit#: � ®0 1 t 2 q 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
FROl1I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Pnblic ft. it in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT. .
Irrigation FROM TO MATERIAL EMPLACE ME METHOD&AMOUNT
Non-Water Supply Well: © ft. 0 ft. 8 r AN
Monitoring Recovery
Injection Well: ft tt
Aquifer Recharge Groundwater Remediation
19:'SANDIGRAVEL:PACK(if a itcablej
Aquifer Storage and Recovery DSalinity Barrier FR011f TO MATERIAL, E6iPLACEbfF,NT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control
Geothermal(Closed Loop) DTracer 20:DRILLING10G attach:additionalsheetsifnecessa .
Geothermal(Heating/Cooling Return) FlOther(explain under#21 Remarks) FROM TO DFSCRIM N color,hardness,soillrock tti a in size,etc.)
0 fi. ft.
4.Date Well(s)Completed: ' 7—11 Well ID#
5a.Well Location: ® ft. 7-00 tt. r ro q
I t7A i scrSl,�ur� bl��s. A �- ft. ft.
Facility/Owner Name Facility IN(if applicable)
A lAe— Wool
ft. ft.
Phy �Add s,City,and Zip oT T a
� i ] -3 3154 a 1 21:REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(if well field,one]at/long is sufficient) 22.Certification: u"�
6.Is(are)the well(s) Permanent or DTemporary ignature o ertificd Well Contractor Date
By signing this fornt,I hereby certify that the tiell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or dNo with 15.4 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: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 700 (fL) 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@100D construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"/+" 1617 Mail Service Cep ter,Raleigh,NC 27699-1617
11.Borehole diameter: 10 (in.) 24b.For Infection Wells: In additiion 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: ti(I G lr / construction to the following:
(Le.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) d``� Method of test: 24c.For Water Supply&Iniecinon 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: h-4 _ 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