GW1-2022-05427_Well Construction - GW1_20220523

ELL CONSTRUCTION RECORD (GW-1) F r Internal Use Only:
1.Well Contractor Information\
::
�''1�-t I l.k )1 1 5 6 14.WATER ZONES
Well Contractor
(t�r
or Name
^ FROM TO DESCRIPTION
NC-WC,
li ` 04
ft. ft.
NC Well Contractor Certification Number
15,OUTER CASING(for multi-cased wells)OR LINER if ap licable
LQ ELL
pw �, ` C FR M TO DIAMETER THICKNESS MATERIAL
�J l ft. 1 ft. � in.
Company Name � r )(Ci
lb. NNER CASING OR TUBING eothermal closed-loo )
2.Well Construction Permit#: FRC M 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.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in
hidustiial/Commercial Residential Water Supply(shared) 18.G ROUT
Ili-i ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. c
t
Monitoring []Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.Q AND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FRO VI TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test [3StormwaterDrainage ft. ft
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) Tracer 20.1 iRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) rl Other(explain under#21 Remarks) FRO TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ft t ft.
e�
4.Date Well(s)Completed:5—i I— Well ID# ft. Put ft.
Sa.Well Location:
C ft ft.
Facility/Owner Name Facility ID#(if applicable) ['
(�J- �i� a,590 V1 i Tt
Physical Address,City,and Zip
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.Certification:
N W V
6.Is(are)the well(s) Permanent or 13Temporary yysigning
re of Certified Well Contractor Date
this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 11Yes or No A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a wpair,,fill out known well construction ill 1,aaatiora a, explain true natu a of the copy o'this record has been provided to the well owner.
repair under#21 remarks section at-on the back of this form.
23.Si a 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: 'O�tld (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiljerent(example-3@,2``00'and 2@ 100') constriction to the following:
10.Static water level below top of casing: —fU� (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: W (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
.Well construction method: A)
above also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) r� constriction to the following:
li
Di ision 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 Supplv& Injection 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:� 6- Amount: t3 compl-tion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Oual tv-Division of Water Resources Revised 2-22-2016