GW1-2022-06461_Well Construction - GW1_20220518

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
U�,I V 1 14.WATER ZONES
Y F
Well Contractor Nam FROM TO DESCRIPTION
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a livable)
-Jr N FROM ft. TO ft. DIAMETER in.
TCHICKNESS MATERIAL
Company Name `�� q�
16.INNER CASING OR TUBING(geothermal closed-loop).
2.Well Construetion Permit#: pC�.JLJ�/( FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public �'1�ft. g l ft. in.
❑Geothermal(Heating/Cooling Supply) NIesidential Water Supply(single) 11 ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: et. ft. 1�._htU1lt„_• _ W rL
❑Monitoring ❑Recovery
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 ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM. TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
Q .
Z ft. o
4.Date Well(s)Completed: Well ID# � ! S'Gj7tGf l G(
5a.Well Location: L 2-3ft. � CL
mm G�1 Gll 3fL 2 ft. b C�,t e e.t c �/'
Facility/Owner Name Facility ID#(ifapplicable) Ift. J ft. (^, - 5 M i [V
�-_�oy1 3 ft. ft.
Physical Address,City,and Zip ft. ft.
2L REMARKS P r N !r
County Parcel Identification No.(PIN) Y
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
, ,
(if well field,one laVlong is sufficient) 22.Certification: •l'�i�-'•:-•v 11,1.4
3� t :TJ p O t �1�'i�W 1`vr iJ .irn i�d,.,l�'1'i}+.,�i71� ,(T O�
6.Is(are)the well(s):)(JP,ermanent or ❑Temporary Signature of Cert' ed Well Contra or Date
By signing this form,I hereby certify,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: []Yes or IlNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: Q 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: C� ' 00 Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
If Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
!f water level is above casing,use"+"' n
11.Borehole diameter: (in,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) � Method of test: t
13b.Disinfection type: 1WT Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018