GW1-2022-04943_Well Construction - GW1_20220518

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Inform1atioln:
l 'Q
l k r" A Y\ 1`1 V Y FROM TO DESCRIPTION 14.`WATER`ZONES:,- :.:
Well Contractor Name
�u-3 f-t pC ft. ft. 7tJ�
NC Well Contractor Certification Number 15 OUTER CASING foi;iitulti-ciised'wells`OR INNER(if a "llcable
FROM TO DIAMETER THICKNESS MATERIAL
\\ VV J 1 1 1 I '}' I ft. I Bg ft. in. tr ¢_t t PN
Company Name I Jl_1"1O
36:INNER CASING OR TUBING coth'ernial-closed--loop).
'I.Well Construction Permit#: FROM TO DIAMETER I 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:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:]Agricultural Agricultural [3Municipal/Public ow ft. 3 it. in. C)\2� S�l1
Geothermal(Heating/Cooling Supply) =Residential Water Supply(Single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18;GROUT._
I1Tl ation FROM TO MATERIAL EMPLACEMENT METHOD AMOUNT
Non-Water Supply Well: 0 ft. ao ft' n�rl'1 c�U
Monitoring DRecovery
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(If a lit:ahlc`:. .'- • ;} -
Aquifer Storage and Recovery QlSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test MIStonnwater Drainage a ft. 33 ft #a so Dv�r
Experimental Technology QlSubsidence Control
Geothermal(Closed Loop) �ITracer 20.DRILLING'LOG',(:i tiiclr`additional'sheets if iiecessai )i
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
--I Geothermal(Heating/Cooling Return) I Other(explain under#21 Remarks) ft, It. l 1
4.Date Well(s)Completed: . Well ID# '� ft. ft. , 6
5a.Well Location: ft. 1 ft. A_rA GC
& )n l"�/ 1}�11 "Up ft. ft.
Facility/Owner Name q FacilittyID#(ifapplicable) ft. ft.5�1OA �,d I DEW r,; n Q� C
�Cs�P r5at
Physical Address,City,and Zip
� _58 (:W I 21.REMARKS
County }'l Parcel Identificaatiion No. J(PIN)
�xl�� ifi'i v i llrry
5b.Latitude and longitude in de rees/minutes/seconds or decimal degrees: �'
g g g "{.t�.tihviirll',�ii ii-r.r�.•:,•;.,,.
(if well field,oner l`at/long is sufficient) 22.Certification:
N _ J a U L44 W �t
c
X 9414`1� - -ace
6.Is(are)the well(s) ermanent or QlTemporary Signature ofC tified Well(kntractoV 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: nYes or No with 15A 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 a�d 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: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(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 Center,Raleigh,NC 27699-1617
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:m A nVuq 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
I
13a.Yield(gpm) VS- Method of test: V 24c.For Water Suauly&Iniection Wells: In addition to sending the form to
{ r the address(es) above, also Isubmit one copy of this form within 30 days of
13b.Disinfection type: 1 Amount: `I � 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