GW1-2022-06051_Well Construction - GW1_20220629

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
;.14.WATER"ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
NC Well Contractor Certification Nu er 15.OUTER CASING for multi cased wells OR LINER if" livable
0—ti`1 c�0—A) �`` \ ( mc- FROM TO DIARiE ER THICK�N�S�1S MATE
Company Name (�
2.Well Construction Permit#: � ` 36 Oa� FROMNERCTSOING l-- TI DIAMETERttiermalTHICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. It. in.
3.Well Use(check well use): ft. ft. in.
,SCREEN
Water Supply Well: 17. _.
FROM TO DIAMETER SLOT SUM THICKNESS MATERIAL
Agricultural []Municipal/Public ft. It. in.
Geothermal(Heating/Cooling Supply) EW.idcatiat Water Supply(single) ft• ft. in.
Industrial/Commercial DResidential Water Supply(shared)
18i`GROUT
n hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft �` b fL c oAcnete p�
Monitoring Recovery & ft.
Injection Well: \ re
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL-PACK if:a livable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer ,10.DRILLING LOG attach additional sheets if neeessa
Geothermal g/ g ) (explain ) FROM TO DESC ON color,hardy soiltrock a in s' etc
(Hearin Coolin Return Other under#21 Remarks ft. % r, —
4.Date Well(s)Completed: °1 Well ID# ft. ft. D {— z
5a.Well Location: (j ft. -sit.
ft.
Facility/ er�Nrame Facility ID#(ifapplicable) ` ft. ft. ^�` �.l�
Physical Address,City,and Zip 12ft. ft. JUN 2 9 202?
-2L RF.MARKR - -- - t 1-..:"9 �' •r;;.'. _
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.Ce cation-
�� `:W6 N Sa° '36 ' r, W I r a
6.Is(are)the wells) Permanent or Temporary Signature of Certified well Contrac or Date'
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: [DYes or O 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.
wed' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 00 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'a(n�d 2@I00) construction to the following:
10.Static water level below top of casing: 7S (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"%,,if 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: C. 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method:etc above, also submit one copy of this form within 30 days of completion of well
�
(i.e.auger,rotary,cable,direct push, .) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: .c 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: C 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: �'� 7 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
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