GW1-2022-05676_Well Construction - GW1_20220615

I
WELL CONSTRUCTION RECORD (GW-1) F r Internal Use Only:
1.Well
Contractor Information:
DA } L C 14 WATER ZONES
Well Contractor Name F M ITO DESCRIPTION
r 7/� .
N QIV c l ,� 36_. � ft. ft ft,
NC Well Contractor Certification Number
15OUTER CASING for multi-cased wells OR LINER(if a licable)
��� ") 1 FR M TO DIAMETER LTTHFICKNESS MATERIAL
" 11-�� � r ft. O t ft. ?V L
CompanyName
16. NNER CASING OR TUBING(eothermal closed-loo )
2.Well Construction Permit#: FR TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC Cotuuv,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17,SCREEN
FR TO DIAMETER SLOT SIZE THICKNESS MATERAAI.
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared)
18.OROUT
'Irrigation FR M TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 9 ft. a It, •o 0 an
Monitoring DRecovery
Injection Well:
Aquifer Recharge E3Groundwater Remediation ft. ft.
:)Aquifer Storage and Recovery 19. ND/GRAVEL PACK(if applicable)
A
q g ry 0Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stornwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20. ILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ClOther(explain under#21 Remarks) FR TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ft. i ft.
4.Date Well(s)Completed:�D �� oZ�Well ID# 11
ft• I ft. gl�
Sa.Well Location: �/� a % ft.
Dky 1� V to lA �Q Jl l ft, ft.
Facility/OwnerName ( 1 9�� Facility
IID##(ifapplicable) I ft. ft.
S�ef_4 r ehuoc h t� I�Q�7TT1`ti�Y� t(� d ft. ft.
Physical Address,City,and Zip ft. ft.
OJ I!I I) 21. MARKS
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.C tit-Ieation:
N W `
6.Is(are)the well(s) Permanent or Temporary Sig;at ge of Certified Well Contractor Date
By#g Ung this firm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or9..xplain
No 1 1 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repait•,.lill out known well construction h4brntation the nature o/'the copy o his record has been provided to the well owner.
repair under#21 renarlts section or o:the back of this,rni.
23.Siv diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Your iay 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 constrt ction details. You may also attach additional pages if necessary,
drilled: t t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I (D (ft•) 24a. r All Wells: Submit this form within 30 days of completion of well
ror nudtiple wells list all depths if different(example-3 tt 200'and 2@100') constr u ction to the following:
10.Static water level below top of casing: 1
(ft.) Division of Water Resources,Information Processing Unit,
If wale,•level is above casing,use- " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:�x (in.) 24b. r In•ection Wells: In addition to sending the form to the address in 24a
12.Well construction method: X( J7(� above also submit one copy of this forni within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.)
constr tion to the following:
DiV sion of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) LDO Method of test:, 24c. r Water Stionly& In•ection Wells: In addition to sending the form to
a
p_r the ress(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1 GL Amount: :�® compl ion of well construction to the county health department of the county
where onstructed.
Form GW-1 North Carolina Denarnment of Environmental Oualilt -Divisinn of Water Reanuroea