GW1-2022-05681_Well Construction - GW1_20220616

WELL CONSTRUCTION RECORD GW-1
F r Internal Use Only:
L Well Contractor Information:
Well Contractor Name 4.WATER ZONES
`� ��+tn y�- R M TO DESCRIPTION
LV G 1!Y ti ��3 ft. ft.
NC Well Contractor Certification Number ft• ft.
15. UTER CASING for multi-cased wells OR LINER(if a licable)
R M TO DIAMETER THICKNESS MATERIAL
Company Name It. t ft. &I5 in, lo V
m
2.Well Construction Permit
15. NNER CASING OR TUBING( eotheral clos d-lloo ) i#: etc.) ft.F M To
List all applicable well consurictioir permits(i.e.U1C,County,$[rite,Pariance, DIAMETER THICKNESS MATERIAL
ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17, CREEN
Agricultural 0Municipal/Public Fit M TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Geothermal(Heating/Cooling Supply) ft• ft. in.
g Residential Water Supply(single)
Industrial/Commercial ft• ft. in.
Residential Water Supply(shared)
it i ation 1 ROUT
Non-Water Supply Well: F M TO MATERIAL EMPLACEME T METHOD&AMOUNT
ft. t ft.
Monitoring Recovery
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation ft ft.
Aquifer Storage and Recovery Salinity Barrier 19, AND/GRAVEL PACK if a licable)
FR TO MATERIAL 'EMPLACEMENTMETHOD
Aquifer Test oStonnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) MTlacer 20, RILLING LOG(attach additional sheets if neeessar )
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FR TO DESCRIPTION(color,hardness,soil/roe type,grain size,etc.)
ft. t ft.
4.Date Well(s)Completed: — -SUL Well ID# ft. r1�ft. r
5a.Well Location:
t C
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
t t
1 ft. ft.
Physical Address,City,and Zip ft. ft.
21. EMARKS
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 rtification:
N W t
6.Is(are)the well(s) Permanent or Temporary gtr re of Certified Well Contractor
Date
X" N'
By S' ing this.1b in,I hereby certilp that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well• []Yes oro with 1 A NCAC'02C.0100 or i5A NC.'AC 02C.0200 Well Construction Standards acid that a
ll'this is a iepair•lill old known well construction infbrinationplain the uattwe ol'the opy _'this retard has been provided to the well owner.
repair under#21 remarks section or a:the back ol'this form.
23.Si a diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You I 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 consti iction details. You may also attach additional pages if necessary.
drilled: J
( SUB IOTAL INSTRUCTIONS
9.Total well depth below land surface:
Formultiple wells list all depths it'di/jereat(example-3@21)0'and 2�100') (ft') 24a. or All Wells: Submit this form within 30 days of completion of well
^^ constr ction to the following:
10.Static water level below top of casing: l J (ft.) Division of Water Resources,Information Processing Unit,
11'water level is above casing use"•top,
(11.Borehole diameter: 1617 Mail Service Center,Raleigh,NC 27699-1617
(in.)
24b. r In'ection Wells: In addition to sending the form to the address in 24a
12.Well construction method: r above also subunit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc,) constt I ftion to the following:
FOR WATER SUPPLY WELLS ONLY: Di sion of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
< ^7
13a.Yield(gpm)_1� _ Method of test: A, 24c. I jL Water Supply&in Wells: In addition to sending the form to
the a ress(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount:_ 30 compl ion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Ouality-Division�f w.ta u­.,,,•e� __...