GW1-2022-04192_Well Construction - GW1_20220419

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.(Well
Contractor Information:
LET1 A Ck/ 14.WATER ZONES
-�1 FROM TO DESCRIPTIO
Well Contractor Name
44-1 ft. ft
1/r]'�
V ft. J ft- `
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells O I LINER if a licable
namdJ / r ,V 4. viumann FROM TO DIAMETER T®C 'JS MATERIAL
(/(N�/ j) ft. 9 ft in. 54
CoInpany Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): tL ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER ! SLOT stZE TIUCKIYESS MATERIAL
Agricultural E-:Y icipal/Public !C 7 J
Geothermal(Heating/Cooling Supply) _ esidential Water Supply(single) ft. ft. in.I 7
r Industrial/Commercial Residential Water Supply(shared) 18.GROUT i
hTi ati0n FRO TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Sup Well:
Monitoring I Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer RechargeGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recov ;Salinity Barrier FROM TO MATERIA EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Lft�perimental Tee ogy OSubsidence Control ft. ft.
ermal(Cl ed Loop) ;Tracer 20.DRILLING LOG attach additional sheets if necessahermal eatimdCooling Return i Other(explain under#21 Remarks) FROM To DESCRIPTION rntor hardness,soiurock in etc.
�( O ft. d ft. �JJ 'Sall
4.Date Weil(s)Completed: I v Well ID# ft. ft ,
5a.Well Location: ft. l ft.
ft. 0 ft. .e- S
Facility/OwwnerName V Facility ID#(ifapplicable) ft, G!J ft. i
I 5 ft ft. APR
k
Physical Address,C�i ,and Z� (J ft. ft.
mIC`-1-1 21.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.Certificati
N W kl-z G��'��
6.Is(are)the well(s) _Permanent .or Temporary Signatuk of Certified Well 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: EJYes or No with I5A NCAC 02C.0100 or 15A NCAC 01C.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: /7 Q (ft-) 24a. For All Wells: Submit this jform within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00� 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: fin.) 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: -44JAYI24c.For Water SuDDIv&Iniection Wells: In addition to sending the form to
If the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 0 Nf Amount: p7 y 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