GW1-2022-05754_Well Construction - GW1_20220601

WELL CONSTRUCTION RECORD (GW-1) or Internal Use Only:
1.Well Contractor Information:
` )AJ` ES D kill 1 ��1 InSan 14 WATER ZONES
Well Contractor Name F OM TO DESCRIPTION
MOW- 4&M ft. ft
NC Well Contractor Certification Number 151 OUTER CASING for multi-cased wells)OR LINER(if a licable)
o FROM TO DIAMETER THICKNESS MATERIAL
ft I t ft. I W t;L5 in. VC,
Company Name e�*��,�n� 16.INNER CASING OR TUBING(geothermal closed-loop) 1G
2.Well Construction Permit#: O�01010(JU 110 FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well constrnctiau permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.IM
REEN
FR TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft. in.
Geothennal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial KResidential Water Supply(shared) 18.OROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. VI
•
Monitoring Recovery
Injection Well:
rl ft. ft.
Aquifer Recharge Groundwater Remediation
19. AND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test [3StormwaterDrainage
Experimental Technology In Subsidence Control
Geothermal(Closed Loop) Tracer 20.ORILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock e, rain size,etc.)
qr `_r ft.
4.Date Well(s)Completed:6—a r/4sL p` Well ID#W oW 1-7� r ft. s ft.
5a.Well ocation: � 40 ` •
G V 6 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
LEAk LN, I lb- M(dh1 5,11L 9SQ& ft. ft.
Physical Address,City,and Zip ft. ft.
OAERA� 21. EMARKS
County CI `� Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.C rtification:
N W _01to_ -2
6.Is(are)the well(s) Permanent or Temporary Sig at re of Certified Well Contractor Date
( By igzing this form,1 hereby certifv that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or No wi I 1 A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
!/'this is a r•epairjill out known well construction information a explain the nature o he c py o this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis jornz.
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 const ction details. You may also attach additional pages if necessary.
drilled: SUB ITT
INSTRUCTIONS
9.Total well depth below land surface: !4ci& (ft.) 24a. or All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if'di#er•ent(example-3(POO'and 2@100') consti ction to the following:
10.Static water level below top of casing: Division of Water Resources,Information Processing Unit,
1/'water level is above casing,rise" ' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:_b_(in.) 24b. or Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: constr ction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
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) M18 Method of test: A1 24c. F r Water Supply &Injection Wells: In addition to sending the form to
--��//�� the ad ress(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: MJL,J comp/ tion of well construction to the county health department of the county
where onstructed.
Form G W-1 North Carolina Department of Environmental Quali y-Division of Water Resources Revised 2-22-2016