GW1-2022-06525_Well Construction - GW1_20220503

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.WtaC
tor Iefn,•raati n:
a3� •14:.wATER ZONES-C. - .'. r ;...... ....-'..:: :. .. ... .
Well�tria ame FROM TO DESCRIPTrON A ft ft. i
ft ft l
NC Well Contractor Certification Number 15:OU7 ER:G�ASING,(fo"r multi-rased wells OR-
Morgan 'immg of -'licable'
Well&Pump, Inc. FROM DIAMETER TMCMWMS MATERIAL
Company Name +1 ft ft- 61/8/ in. sdr21 pvc
16."EMR CAS134G OR T0BIIVG.('eothermal
2.Well Construction Per t#: VJ�Q�/,/ FROM TO DIAMETER rMcla Ss MATEF2LIL
List all applicable well con ucton permits'fi e.UIC,Cowity,State,Variance,etc.)- ft ft. in.
3.Well Use(thee ell use): ft ft. in.
Water Supply ell: 1A:SCREEN', ::. .`�: ::::: r:.•: :•'.'. '..:'�,::=. ._,. :'r::.:. .. ::
FROM TO DIAMETER SLOT SIZE THICKNESs MATERIAL.
Agricultural r-ilMunicipal/Public ft ft in:
Geothermal(Heating/Cooling Supply) IBResidential Water Supply(single)
ft ft
I Industrial/Commercial Residential Water Supply(shared) ::18i GROUT-.`-_
E hii ation FROM TO MATERIAL - EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft• bentonite poured
Monitoring DRecovery ft. ft
Injection Well:
uifer Recharge �—,� ft ft
A
q g t�lGroundwater Remediation ,:19:SAND/GRAVEL-PACK if a`licabl'e
Aquifer Storage and Recovery ©II Salinity Barrier TO - MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage- ft ft
I Experimental Technology Subsidence Control ft
FROM , ft
i,Geothermal(Closed Loop) 1ITracer :20.DRUJ:aNG.LOG'(fittiiE'dditi6n'sl shee6,if ae6ess--)':;' >'=
Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(colo,hardness,soillrack typ,, in size,ete_)
.
4.Date Well(s)Completed: Well Well ID# b ft b ftf
�.. ft-
36 ft. r
5a. ell Location: S ft D ft
a G D ft Q ft
Facility/Owner Name Facility ID#(if applicable) ft
2A t CAS.I l Se4�c k?u (Lhu rc� -2 ft -
P sical Address,City,and Zip ft O
Y /1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2 cationl
N lib.71dl W 3
6.Is(are)the well(s)�il Permanent or _I Temporary /Sigpna Well Contractor D e
form,I hereby ce•t�that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©'Yes or JENo C 02C.0100 or 15A NCAC 02C..0200 Well Construction Standards and that a
Ifthis is arepairfill out known well construction information and explain the nature ofthe ord 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
dried'— 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 ifdierent(example-3Q200'and 2Q100� construction to the following.
10.Static water level below top of casing: 'V (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
t above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: LI construction to the following:
(i.e.auger,rotary,cable,direct pusb,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) air pressure 24c.For Water Supply&Iniectioh Wells: In addition to sending the form to
LL.� Method of test: g
the address(es) 'above, also submit;one copy of this form within 30 days of
13b.Disinfection typ : Amount: I completion of well construction to the county health department of the county
where constructed_
Form GW-1 Nortb Carolina Department of Envimmnental Quality-Division of Water Resources Revised 2-22-2016
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