GW1-2022-06218_Well Construction - GW1_20220620

Print Form'
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well
/Contractor
'Information: //
C ad F S G/i 11LI? _ 14.WATER ZONES
FROM TO
DESCRIPTION �(
Well Contractor Name 2 C Sim ft. Q - Sur L t LL I /] U t P r.J rdl�
3 e 7y1 4 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased-Wells OR LINER if a lieable
FR0111 TO DIAMETER THICKNESS MATERIAL
in.
Company Name G 16.INNER CASING OR TUBING(geothermal closed-loop)..
/-
2.Well Construction Permit#' ��L �Y N/1 A / 4� -���`� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable bell cons0vction permits(i.e.UIC.County;State. 4 lance•etc.)
ft. ft. in.
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in.
IndustriaUCommercial oResidential Water Supply(shared) 18.GROUT
?. FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Irri anion �-•''•�_�
Non-Water Supply Well:0.
'' '�•��..•��.:v4�-i""� •� ft. ft.
Monitoring Recovery 111hift. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwat r Remediation SAND/GRAVEL PACK if applicable)
In orar�tc-nf ''gin^"
Aquifer Storage and Recovery DSalinity Barrier V�,y�c� ` tlM1t TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Storrnwater Drainage ft• ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessa
FROM TO DESCRIPTION(color,hardness,sail/rack h e rain size,etc.
Geothermal(Heating/Cooling Return) r3Other(explain under 421 Remarks) � S• ft. ked a regde •h brgvcd"ev-Sa r 0A4
4.Date Well(s)Completed:5-a Z'ZL Hell IDt/�'/ /� I /S ft' S ft. -!14V IS ro v h 4V's '--:r rp L
5a.Well Location:
Ur/--er 8 e(,
Y lec� ft. rc. f'a/fAr�(j
Facility/Owner Name I yy Facility ID#(ifapplicable) ft. ft.
(t. ft.
ft. ft.
Physical Address,City.and Zip
21.REMARKS r!
pOL v i'ds 0 /v Parcel Identification No.(PIN) P Gl,�C U.b 0�Aa��/V e c
County _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: W/ �� C rr�r 'a fte
(iftvell field,one lat/long is sufficient) 22.Certification: fi
Signature of Certified Well Contractor Date
6.Is(are)the well(s)oPermanent or Temporary ��
Br signing this frnnn•I herebv cerli�i•that The tvell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or �No ,ridt 15.4 AICAC 02C.0100 or 15.4 NCAC 02C.0200 Well ConstructionSTandards and that a
If this is a repair.fill out known well construction inforutation and explain the nature ol7he copv of this reco d has been provided to the rrell owner.
repair onder 01 remarks section or on the back of this form. 23.Site diagram or additional well details'
8.For Geoprobe/DPT o 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 l GW=1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.r
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 nndriple wells list all depths ifdi(ierew(example-3 a 200'and 2C 100') construction to the following:
10.Static water level below top of casing: (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: b (in•) 24b.For Iniection Wells: In addition to sending the fonn to the address in 24a
So r-C 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: 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: 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