GW1-2022-06043_Well Construction - GW1_20220629

WELL CONSTRUCTION RECORD (GW-gl For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name It. IL
fit. fit.
le
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased we lls ORLINER a Ii
FROM TO DIAMETER TIH ESS MATERIAL.
lS ft. �V(i
Company Name 16.INNER CASING OR TUBING eotlrermsl closed-lao
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: d ft. / ft. in.
List all applicable well construction permits(i.e.UIC,County.State.Variance,etc.) 7 fit. in.
ft.
3.Well Use(check well use): 17
.SCREEN Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public I(0 fit. rq��fit. 2 in-
t p(C) mil) aVG
Gcothctmal(Heating/Cooling Supply)
Residential Water Supply(single) fit, ft. in.
Industrial/Commercial Residential Water Supply(shared) 18,GROUT
FROM TO MATERIALL EMPLACEMENT ME HOD&AMOUNT
Irrigation I 1 IL [S fL be,,fwi<t,e Chi �J✓`�(
Non-Water Supply Well: J /
Monitoring
Recovery ft, 3 ft. pof k"d (f-rz,_-
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK a lecsb8e
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
N
Aquifer Test �Stormwater Drainage �LjZj fit. r�'p
Experimental Technology
Subsidence Control ft' ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additionel.sheets ff necessa
FROM TO DESCRIPTION color,hardness aoufmcktype, rain siu,etc.)
Geothermal(Heatin Cooling Return) Other(ex lain under#21 Rem``arrks) O ft. G u r Gry v(
Zti LJ (�" ft Z ft.
4.Date Well(s)Completed: Well II)#
`L r ft. Ll I ft. G ni G C(c
5a.Well Location:
1. ft. G$.S ft. ! �W/j,CRC'?
�/a.r0 Lii G 5 bt GDMQL�y�t"L g °r r�/ o- pp}
ft. -ft. A n
Facility/Owner Name
( , Q Facility 1D#(ifapplic
Llable)
& 7 ./ /, , ft. fft
r,..
Physical Address,City,and Zip 21.REMARKS YN
D 1.� `�'ro�t Itd`,9�i''t s(j� n.�,'• ..
'.�l�ilir'rl 1111;-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
% $q2� G1(-( N "?S, &ZC933?
' lure of Certifie ell Contractor Date
6.Is(are)the wells) Permanent or QlTemporary
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.
u kn
t known well construction information and explain the nature of the with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If thi s is a repair,fill out I this a repair existing well: Yes or No 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (fit) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdifferenr(example-3@2700'and 2@100� construction to the following:
lo.Static water level below top of easing: (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+.. 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- 1 (in.) 24b.For 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: (� constnrction 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
24c.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: the address(es) above, also submit one copy of this form within 30 days of
Amount: completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016