GW1-2022-06186_Well Construction - GW1_20220701

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1�I Contractor Infor
14.WATER ZONES
FROM TO DE CRIPTION
Well Contractor Name
ft. 126- ft.
NC Well Contractor Certification Number 15:OUTER CASING(for multi-cased wells)OR LINER(if'applicable)
FROM TO DIAMETER I THICKNESS MATERIAL
Company Name ,A6.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Constriction Permit# FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) R• ft. in.
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Munlc'pal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) !_ sidential Water Supply(single) ft. et. in.
IndustriaVCommercial DResidential Water Supply(shared) 18.GROUT
I"Ilrri ation FROM TO MATERIAL E PLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring ecovery ft. ft.
Injection Well:
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology OSubsidcnce Control
:)Geothermal(Closed Loop) Tracer 20:DRILLING LOG attach additional sheets if necessary)
l Geothermal(Heating/Cooling Return) I . Other(explain under#21 Remarks) I
FROM TO DESCRIPTION(color,hardness,solUiock type,grain size,eta)
ft. ft.
4.Date Well(s)Completed: � �Well ID# ft. ft. .. z '"., �, a b? - L
5a.Well Location-
Facility/Owner Name Facility ID#(if applicable)
Physical Address,6ty,and Zip
9&non '21.REMARKS Q /+
1 -k C'
County Parcel Identification No.(PIN) '
A
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if/we0 field,one ll�atflongisis sufficient) 22. rtification:
N ?qd W
6.Is(are)the well(s)(gYermanent/ or '.J Temporary ignitors of Certified ontractor 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: ET(-s or DNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out mown 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 GV�I 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: (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 002and 2@100D construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
IJwater level is above casing,use"+" r 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: -f (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
L�y� above, also submit one copy of this form within 30 days of completion of well
12.Well constriction method: ^^r I 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: 24c.For Water Supply&Injection 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: ^l fI Amount: . 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