GW1-2022-06181_Well Construction - GW1_20220701

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
®��h 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
s �] �ft. s o ft. '.t'
39
ft. alivl
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL
Company Name I&INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
:)Agricultural E]Municipal/Public 0 ft. ft. in.
:]Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in•
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft. -7 ft. ,
Monitoring DRecovery ft. ft. b�Y7
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ElStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20:DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO Ft. ft. DESCRIPTION(color,hardness,soll/mk tin size,etc.
C,-b.,
4.Date Wcll(s)Completed: .��' �'��Well ID# �� 2 R• is ft. �� L
5a.Well Location: ft. t.
Facility/Owner Name Facility ID#(if applicable) `
ft. ft. — L LL
Physical Address,City,and Zip
,21.REMARKS
SIt:� I
County Parcel Identification No.(PIN)
t.:t'laEi l�l
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one tat/long is sufficient) 2 Icatio
3�a. �8f3s�1o7 N - ?g 341�_bz//9 W
6.Is(are)the well(s) Permanent or [3Temporary Igna of certified Well on 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: OYes 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.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: d/O D (ft.) 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@100l construction to the following:
10.Static water level below top of casing: 4 J (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: 0 S (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: 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) Method of test: ✓t/rb eq 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: HT Amount: L n GG y 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