GW1-2022-04050_Well Construction - GW1_20220422

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Informa'on,
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
40N V4) ft. ft.
NC Well Contractor Certification N er
15.OUTER CASING for imuld-casedivelis OR LINER if n licable
FJi l� FROM TO DiAi1 TER THICKNESS MATERIAL
°1 ft. ft. In. dt V.
Company Name a Qwe t v
16.INNER CA ING(1R TU LING eWhermal closed400
A 2.Well Construction Permit#: (� FROM I TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U1C,Count};State,Variance,etc.) ft. ft. , In.
3.Well Use(check well use): ft. e, in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE I THICKNESS MATERLAL
Agricultural Municipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) 9Residential Water Supply(single) n ft. In.
Industtial/Commercial Residential Water Supply(shared)
U.GROUT
Irrigation FROM I TO MATER EMPLACENU NT MMOD 4 AMOUNT
Non-Water Supply Well:
in
Monitoring DRecovery ft. tt.
Injection Well: ft. ft.
Aquifer Recharge ®Groundwater Remediation 19.SAND/GRAVEL PACK if a ticable
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. I R
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG.attach additional sheets tfnecess
Geothermal(Heatin Cooling Return) r3 Other(explain under#21 Remarks) FROM TO DFSCRHWTON color,hardnem sotlhnck opt,amin sim etc.
ft. ft.
4.Date Well(s)Completed: a Niue.ID# ft. fL
Sa.Well Location:
st. it.
lap 4 Sly.
Facilit3d&ner
�Name { Facility IDO(if applicable) h• R'
����� ft. ft.
Physical Ad ess,City,and Zip
-FJ�4 r ��1,'� a 3 51 x1.REMARKS -
County Parcel Identification No.(PIN) aQ R
5b.Latitude and longitude in degrees/m9nutes/seconds or decimal degrees:
(ifwellfiield,one lat/longissufficient) 22.Certification: 't'ra7'JJ"J
6.Is(are)the weR(s) Permanent or Temporary SignatlofCartified Well Contractor Date i
By signing flits form,I hereby certify that the wellls)was(were)construcied in accordmrce
7.Is this a repair to an existing well: []Yes or No with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If ilds is a repair,fill out known well construction information and explain the nature ofthe 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
constructign,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
dri led: / SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: V t9 (fI) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lfd{fjerent(example-3Q200'and 1®100) 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 Center,Raleigh,NC 27699-1617
11.Borehole diameter:1 (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: t'dT � constntction to the following:
(i.e.auger,rotaryyruc,cable,dtrectpusb,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: �j 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 4/' Method of test: �f� � 24c.For Water Suably&Injection Wells: In addition to sending the farm to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GWA North Caroline Department of Environmental Quality-Division of Water Resources Revised 2-22-2016