GW1-2022-06039_Well Construction - GW1_20220629

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Inform on:
DL Y\n 1 5 �'� Gly vv � 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 5�ft. ft. ` u
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL.
E ft. ft. b ((I-in.
Company Name
r� !� 16:INNER CASING OR TUBING 'eothermal closed-lao
2.Well Construction Permit# 0 `� 1 ©� `�\ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft. fL in.
Water Su Well: 17.SCREEN
Supply FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Mumicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT'
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. O It. C
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
I Aquifer Storage and Recovery OSalinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology I3Subsidence Control ft. ft.
1 Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCBIYT[ON color hardn soil/mck typc in size,etc.
© ft. (0 ft.
4.Date Well(s)Completed: ►Q' a s Well ID# ft. -4 5 , ".
q
a -o ss��jj
Sa.Well Location: ft,an. � � ft. 1� c7rG, D
O It. ft -
Facility/Owner Name` ` Facility ID#(if applicable)
ft. rt.
-3 C) Q- -rc \V1 U ` �,Ll��l ft. ft
Ph ical Address,City,and
Zip �q i �p� ft. ft
W\"%h�.� -1 1�0�����4�1h1V� 21 REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 022.Certification:
-N d" 4-0 ' W
6.Is(are)the well(s) ' Permanent or OTemporary Signature of Certified Well Contractor DatcJ
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or 0< with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 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#21 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: O (fL) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2_@100) construction to the following:
10.Static water level below top of casing: li 10 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+"6 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: fn.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
QQ � above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: � ���"1 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: nn 1636 Mail Service Center,Raleigh,NC 27699-1636
l�
13a.Yield(gpm) A� Method of test: + 24c.For Water SuDDIv&Iniection Wells: In addition to sending the form to
y n + the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Ck Amount: 1 b G completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016