GW1-2022-05741_Well Construction - GW1_20220609

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
J 1 klA 1..+5 JDA n I 0 w 1 t c�o f) 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
�t��� pp303
ft. ft.
6�C C 4 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a licable)
c,,` t t FROM TO DIAMETER THICKNESS MATERIAL
1 [A )C11 R I L l 1 n�l _LNl 0 ft. t ft. 'n m. 'J
Company Name �}[1 a� 1>Ira i Y(I
ry e� ] 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 0�rsl• t pLp( FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constrtrction 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 ®Municipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in,
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Iri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
ft. ft.
Monitoring ®Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
14.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test !3 Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessar )
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
�t1 ft. a ft.
Wei C
Lp Art
4.Date Well(s)Completed: -="a2 Well ID#6,2,; -�r�a�i� lJ ft. 1(41
ft
5a.Well Location:
ft. ft. I
_E*`'' eJ Wt4kbn
Facility/Owner Name�[� Facility ID#(if�apfplicable)
�V ,
Physical Address,City,and Zip
ft. ft.
Gam^Q&:R 4, L1 I 1 21.REMARKS
County CPJarrccellIdentification No.(PPIIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W '
6.Is(are)the well(s) Permanent or Temporary i nature of Certified Well Contractor Date
777��T ,�/ By igning this forma,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or y�No wit 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
#'this is a repair,fill out known well construction information an explain the nature ofth co y ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this,forma.
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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: -t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: C; (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'mad 2@100') construction to the following:
f
10.Static water level below top of casing: 1 w L (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: t(2 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
A c above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1 f h [� 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) 4b Method of test: 1 24c. For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this Porn within 30 days of
13b.Disinfection type: Amount:S 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