GW1-2022-04575_Well Construction - GW1_20220510

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WELL CONSTRUCTION RECORD(GW-1) Fo Internal Use Only:
1.Well Contractor Information:
l
J 1 15 OJ) 14. WATER ZONES
Well Contractor Name TO DESCRIPTION
ft. ft.
4303 A ft. ft.
NC Well Contractor Certification NumbeVr� 15.,)UTER CASING for multi-cased wells OR LINER If a Hcable
\ 1 FR TO DIAMETER THICKNESS MATERIAL
Company Name V\/ W 11'`7 ft. ft. S In,
�,.7 0 2,I cool 16. R CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#; 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: 17.1 CREEN
FRO VI TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) [311gaidential Water Supply(single) ft. ft. in.
Industrial/Commercial esidential Water Supply(shared) iS.GROUT
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. - U ft m r filgn►` (,.r9 vi 3y Ly bags
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge rIGroundwater Remediation 19.1 AND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FRO 4 TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage
Experimental Technology n Subsidence Control
Geothermal(Closed Loop) Tracer 20.1 RILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FRO TO DESCRIPTION(color,hardness,soillrock a rain size,etc.
��11,,,, ft. ') S- ft. co PD�a OC.
4.Date Well(s)Completed:)4dD30 Well ID# 3, It. ! o ft. 6—r-,ni I e p ^,
5a.Well Location: l�0 ft. ft. 0Pco�nose l�vyL
ToTomoo ye. 6ec-tc 1
(r it. o ft. a/11 e
ne Facility/Owr Name Facility ID#(if applicable ft. ft.
Mv(`�h ,l�
Shoal �reel� Poin('@ 10�-fS 2�6SobY ft. ft.
Physical Address,City,and Zip
ft. ft.
Ch ero k e k 21.1 EAIARKS
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.Certification:
N W
6.Is(are)the well(s)E31Perinanent or 13Temporary SiP are ofCertified 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: []Yes or o with 1 A 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 cfthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.S to diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You ay 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 const uction details. You may also attach additional pages if necessary.
drilled: I SUB ITTAL INSTRUCTIONS
9.Total well depth below land surface: —0l0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diifferent(example-3@200'//annd 2@100) const uction to the following:
10.Static water level below top of casing: �tJ (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 Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method pp ,f` � I y above,also submit one copy of this form within 30 days of completion of well
/ `` cons ction to the following:
(i.e.auger,rotary,cable,direct push,etc.))
D vision of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: dd 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of test: f I 24c. or Water Supply&In•ection Wells: In addition to sending the form to
the a dress(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: fil^ r'6110-4"5 Amount: (J completion of well construction to the county health department of the county
when constructed.
Form GW-I North Carolina Department of Environmental Quo lity-Division of Water Resources Revised 2-22-2016