GW1-2022-04054_Well Construction - GW1_20220422

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Wil Contractor Information:
�V x� /hq I&WATERZONES
Well Contractor Name FROM I TO DESCRIPTION
ft I ft.
(/ r� R I ft.
NC Well Contractor Certification Number
n ���lll 15::OUTER CASING:(foe-multi cased ivells):OR LINER.if ii licabte .''
��(J all /�/' I-�/ FROM TO DIAME EIt THICKNESS bATERIAL
IIJJ(t�i ,` ft in.
Company Name
.16 INNER CASING OR TUBING eothecroalrloscd=loo ..
2.Well Construction Permit#: FROM TO DIMIEPEIt THICIaaSS MATERIAL
List all applicable well constructionpermits(t.e.UIC,County,Stag Variance,etc.) ft. Z/afLt in. f 1•l.61
3.Well Use(check well use): ft. ft t°
Water Suppiy Well: 17.SCREEN
FROM TO .:. DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural •etpal/Public ft. it in
Geothermal(Heating/Cooling Supply) 's Residential Water Supply(single) ft ft. in.
IndusWaI/Commercial iResidential Water Supply(shaved)
18,GROUT ;
-- Irrigation FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:. ft. %
Monitoring ORecovery & ft.
In Well:
ft. ft
Recharge Groundwater Remediation
19.SAND/GRAVEL-PACK if applicable):!
. .
Aquifer Storage and Recovery DSalinity Barrier FROM TO I MATERIAL, I EMPLACEMENT hfErHOD
Aquifer Test OStormwaterD coinage ft. ft
( Experimental Technology OSubsidence Control ft. ft.
-Geothermal(Closed Loop) OTraeer 7.20:DRILLING.I OGt atmch additiondl sheets if necessa"
G
eothermal(Heating/Cooling Return) - Other{explain under#21 Remarks)) FROM TO DESCRIPTIONcolor,hardness soiVroek a sire etG
fa It.
4.Date Well(s)Completed: M9 /'Well ID# ft fL
5a.Well Location:
it ft.
Z.: & -1-t' 1-t Atf-y?2- ft ft-
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Physical Address,,City,and Zip ft ft APR 2 !�q 2029-
21:REMARKS....: �.1.,.... p
County Parcel Identif icati on No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ^ ����r'o� G•C "''
(ifwell field,one lat/long is sufficient) 2qCeMenV-2,N FD d 37'OTI vim/# W
6.Is(are)the we➢(s)OPermanent or QITe porary Signature of fled We Con Date
By signing flits farm,I hereby certify Char lire rvell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 91es or F-INo vith ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out Imown well construction information and erplain lire nature of the copy of this record Iras been provided to die well owner.
repair under 1121 remarks section or an 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-1 is needed. Indicate TOTAL NUMBER ofwells _ 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 if d�erent(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
Ifrrater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 24b.For Iniection 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: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supvly&Iniection 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: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016