GW1-2022-06459_Well Construction - GW1_20220517

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
L'r) V r [ I r y 14.WATER-ZONES
FROM TO DESCRIPTION
Well Co/n�tra�c/to'rNae Let
NC Well Contractor Certificatio Number
15.OUTERCASING(for multi-cased wells OR LINER(if a licable
v. C y � ) r n FROM TO DIAMETER THICKNESS MATE,R`IAL
-1'C' `7Lde 1 ��1 I 1 �f ft ft. in. �. L,() V
Company Name
(� Ifs 16.INNER CASING OR TUBING eotherntal closed-lob
2.Well Construction Permit#: g ©a , t 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.
17.SCREEN:.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:)Agricultural [DMunicipal/Public (�� ft. 1 ft. in. I O/P SG �C.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18:GROUT,:
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. Q����; 6uyi - -l 2- )5-0 1 b
C-Monitoring Recovery
Injection Well:
ft. ft.
_ Aquifer Recharge Groundwater Remediation
'19:SAND/GRAVEL PACK(if a' licablc) _
_ Aquifer Storage and Recovery ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
D Aquifer Test rJ,IStonnwater Drainage O� ft. D ft
Experimental Technology FnISubsidence Control ft. ft. c�
bGeothermal(Closed Loop) MITracer 20.DRILLING.`LOG(atfadi additional sheets if recess"ar
FROM TO DESCRIPTION(color,hardness,soil/rock type, •rain size,eta)
_ Geothermal(Heating/Cooling Return) ,I Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: �d Well ID# ft. ft. A lay fah thil
ft. ft. U/h Ir e sal �/ CL
Sa.Well Location:
e� 3 ft. S2 ft. CI M d- shell
Facility/Owner Name ) /� ) ] F�accili/tyyID#(if applicable) �� ft. � ft. UG F--••
_I /I 0 3e P/OI IQS rill U)y6A & 1. OL5 n6(lKa 8' 57Li ft. 11 ft. c.. Uk
Physical Add ess,City,and Zip q q ft. b ft
21.REMARKS 1? t�g� M1 t'
I� en
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if field,one lat/lon is sufficient Cr ya s`?; �4�
C g ) 22.Certification:
3` 30 U N /V �! t ` 1C� W �� . , -0:1i1, r i1lJ,ri'3ti•''r�ry n_
P O/mil/
6.Is(are)the well(s) ermanent or 3Temporary Signature of rtified Weii ntractor 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 a kplain the nature of the copy of this record has been provided to the well owner.
repair under 4121 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: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 100') constriction 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: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
�j above, also submit one copy of this form within 30 days of completion of well
12.Well construction method:_ lit U r o}�Y�/ 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) f Method of test: P L4 M Ip 1 rn 0) 24c.For Water Supply&Iniection Wells: In addition to sending the form to
,g_ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: I Amount: Z GLk 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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