GW1-2022-06680_Well Construction - GW1_20220708

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
C0i 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft_ . ft.
3 i 76f /4 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER if a liCable
r`1 t. / •� FROM TO DIAMF,TF-R THICKNESS MATERIAL
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAI,
List all applicable hell construction permits(i.e. UIC,Coaniv,State. Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. R. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER, SLOTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public f[. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in•
htdustriaUCommercial Residential Water Supply(shared) 18.GROUT
Irrl ation FROM I To MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring DRecovety
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(ifapplicable
1 Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OlStonmvater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) DITracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
4.Date Well(s)Completed: " Well 1 D# ft. 1 ��
p ..
5a.Well Location: ft. ft.
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Facility/Owner Name _` Facility ID#(itapplicable) ft. ft.
l/ ) t` , r^` ft. rr. In�arirta �,� 4�ruC: ;°t3 r;t
Physical Address,City,and Zip ft. ft. J v
Mc.
e./ A-,/C!/_ o' c'1 21.REMARKS {,
County Parcel Identification No.(PIN) em A•So
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ��' l' Gv h ��� ' "� jai Jedeb
(ifwell field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s)oPermanent or OTemporary Signature ot'Certitied Well Contractor Date
6v signing this frn'n. I herebv ceiWl.v that the melfls)was(,eery)constructed in accordance
7.Is this a repair to an existing well: Dyes or C@ No with 15A NCAC 02C.0100 at 15A NC4C 02C.0200 Ikell Consn,tction Standards and that a
ifthis is a repair.fill oul known well construction hif"i'mation and explain the nattu'e ol'the ropy pfthis record has been provider/to the well onner.
repair under 421 remarks section or un the bark uflhis fm'm.
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 wails construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: f 0 A) 24a. For All Wells: Submit this, form within 30 days of completion of well
For multiple,yells list all depths ifchljereut(example-3@;200'and @(,'/00') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
jf carer level is above casing,mse •+� 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
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1method:
above,also submit one copy of this form within 30 days of completion of well
(i.e Well construction method
.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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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 t i the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Rcvised 2-22.2016