GW1-2022-06679_Well Construction - GW1_20220708

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
I G�°
1 ��,f,
I �/ /'1't � r / 14.WATER ZONES �
FROM TO DESCRIPTION
Well Contractor Name
ft.
7 G A ft.
ft. ft.
I.
NC Well Contractor Certification Number 15.OUTER CASING(for mu1H-eased`weBs OR LINER If a BCable)
FROM TO DIAMETER THICKNFSS MATERIAL
7 i fl. ft. in.
Company Name 16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well c•onsuvction 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 Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
IndustriaUCommercial DResidential Water Supply(shared) IS.GROUT
Irri ation FROM TO MATERIAL EMPI,ACFMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring ORecovery
Injection Well:
rt. n.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QlStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/rock type,grain size,etc.
a rt. ft.
e —
4.Date Well(s)Com letd4 -24) Well ID# ' Gx li f:7
ft. ft.
5a.Well l Location:
C>�c� l/U11Gi.NIn Y 2/ 6 rL rL =�
PP= ?^
Facility/Owner Name Facility ID#(if applicable) J
Physical Address,City,and Zip ft. ft.
/ 21.REMARKS
County Parcel Identification No.(PIN) �' '�! t'-.S LV e-� cC p4c� CiI, C, , 1'SeC M rn
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i'' t rCv! G
(if well field,one lat/long is sufficient) 22.Ce tifieati n:
6.Is(are)the well(s)oPermanent or oTemporary Signature of Certified Well Contractor''- Date
By.signing this jinn,, I herehv certy.v that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [DYes or WNo with/5A NC,4C 01C.0100 or 15.4 NCAC 02C.0100 Well Construction Standarcls tad that a
If this is a repair,fill out known well conslruc•tion in0 oration and erplain the nature of the copy of this record has been provided to the well owner
repair under#21 remarks section or an the back o/7his fohvn.
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 I GW-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: / 0 (ft.) 24a. For All Wells: Submit this' form within 30 days of completion of well
FOP multiple wells list all depths ifdi//et'ent(example-3@2000'aand 2 rerinn') construction t0 the following:
10.Static water level below top of casing: /►'/ / (ft.) Division of Water Resources,Information Processing Unit,
/frater level is above casing,we + 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the font to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: _5 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
1 `
13a.Yield(gpm) Method of test: 24c. For Water Supply& Injection Wells: In addition to sending the form to
the address(es) above, also subunit one copy of this font within 30 days of
13b.Disinfection type: Amount: completion of well construction t I 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