GW1-2022-05460_Well Construction - GW1_20220603

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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14.WATER ZONES '
FROM TO DESCRIPTION
Well Contractor Name W ( I A O ft- n ft.
r�J // 4/2/ZZ 6136fL ' ft- . I vrc e
NC Well Contractor Certification Number /n/ ) 15.OUTER CASING for ells OR LINER if a livable
�p••/S n�I�I/e�l Nr/��/ L�/ FROM TO DIAML'1'ER T�CKNESS -MATERIAL
Company Name G► ft- ft.
/o1S n�� 16.INNER CASING OR TUBING eothermalvclvosed-loo I
2.Well Construction Permit#: FROM To DIAMETER TE11c[avFss MATERw.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) D ft. 1°'
3.Well Use(check well use): ft. ft. in.
17.Water Su Well:
PPIY FROM SCREEN
OM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public 0 ft. ft. in.
:)Geothermal(Heating/Cooling Supply) Ji 1residential Water Supply(single) g, M in.
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
I Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft C) fr e/J d Qa%
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SANDlGRAVEL PACK ifs livable
j Aquifer Storage and Recovery IJ Salinity Barrier FROM TO MATERIAL EMPLACEMENT NMTnoD
Aquifer Test OStormwater Drainage h- ft.
I Experimental Technology OSubsidence Control ft. ft.
'Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets if necessary)
1 Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROMg2r'
TO DESCRIPTION(color,hardness,soil/rock in size,etc
4.Date Well(s)Completed:-= 1� Well ID# 0 ft. emu/
5a.Well Location: -, f� o Fr oC/ / z;
Sic U�l � ® ft
Facility/Owner Name acility (ifapplicable) ft ft
JZ3 I<eln, a-"r-- � 7
Physical Address,City,and Zip 11 7
21.REMARKS
STD
County Parcel Identification No.(PiN)
d+,PflC'.'PT'.., ..._.r nr_r^••'.+.tlfZtj'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
C ^�
N W
6.Is(are)the well(s)orermanent or OTemporary Sig of rtified WM Contract Da
By igning this form,I hereby ce �that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or &ro' with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 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#11 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: `7d (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 1@100') 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 Infection Wells: In addition to sending the form to the address in 24a
oT r�/ 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) lU tl/ ri/ Method of test: ��yl� 24c For Water Suably&Injection Wells: In addition to sending the form to
G 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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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