GW1-2022-06184_Well Construction - GW1_20220701

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
n�I/i✓1 /7 14.WATER ZONES
4it FROM TO DESCRIPTION
Well Contractor Name
ft.
NC Well Contractor Certification Number 45.OUTER CASING for maid-casid-mess)OR LINER(if applicab(e).
FROM I TO DIAMETER THICKNESS MATERIAL
7 •�`jls /�l'- ft. ft. % in. G
Company Name 16.1NNER CA5 G OR TUBING eothermal closed-loop)'
2.Well Construction Permit#: 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. ft. in
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE I THICKNESS MATERIAL
( Agricultural 3Municipal/Public 0 ft. ft. in•
Geothermal(Heating/Cooling Supply) 5XIlidential Water Supply(single) ft. ft- in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. �? r•
:)Monitoring :_.Recovery ft, ft.
n
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 164
-19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage
Experimental Technology OSubsidence Control ft, ft. d -
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if nmessa.
Geothermal(Heating/Cooling Return) nOther explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,eta
ft. ft.
4.Date Well(s)Completed: = ell ID# bi ft, ft. 54--le'?
5a.Well Location:
7 d'l�S �L2�rgZ ft. ft.
Facility/OwnerNaine/7 /ff Facility lD#(if applicable)
L� � ,Ld �r J X�C3�0 ' ft. ft.
y/ '�.;d
Physical Address,City,and Zip ft. ft.
2L REMARKS- L
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 adon:
N W.
6.Is(are)the well(s) ermanent or Temporary Sigoa a of Certified Well Wntnktor 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 EaKo with ISA 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
I�
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 4� Y(,/� (ft) 24a,For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10..Static water level below top of casing: Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this fomi 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: J6f((Df.JPL &L d -For Water Supply&Iniection Wells: In addition to sending the form to
J� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: J 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