GW1-2022-06808_Well Construction - GW1_20220718

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WELL CONSTRUCTION RECORD (GW-1) Fo Internal Use Only:
1.Well Contractor Information:
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Well Contractor Name �6 FROM TO DESCRIPTION
(/+ f" 30(�
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NC Well Contractor Certification Number
ellContractorCertificationNumber 15.OUTER CASING&r maltt:Eased wells OR LINER if a Bcable)
1 J I 1 ��/I 1 �,)G�� ��` 1 I t ► 1 Vl J.�l.� �O ft.M I TO I ft. DIAME^ElR ln. THICKNESS MATERIAL
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Company Name 16. ER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 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.
Water Supply Well: 17. CREENFROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural rIMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial 1DResidential Water Supply(shared) 18. ROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Cft. t ft.
Qord
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation
19. AND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery ®Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®Stormwater Drainage ft. ft.
Experimental Technology n Subsidence Control ft. I ft.
Geothermal(Closed Loop) nTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks)
TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ks) faLL01 ft.
4.Date Well(s)Completed:-13-tlU Well ID# Vi
5a.Well Location:
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Facility/Owner Name Facility ID#(if applicable) Q/, ft. ft.
`11TX al �c1'P.�S`(I I t e- 1�1 ci Q 9ay ft. ft.
Physical Address,City,and Zip ft. ft.
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
s
�f N W
6.Is(are)the well(s) Permanent or Temporary i e of Certified Well Contractor Date
By s ning this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or keisxplain
o with 5A 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 the nature of the c this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.S ite diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You nay 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: SUB UITTAL INSTRUCTIONS
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9.Total well depth below land surface: 1 L4 W (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
11AA . abov,also submit one copy of this form within 30 days of completion of well
12.Well construction method: K4 I a 11 F 1 � 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) Method of test: 24c. For Water Supply&In'ection Wells: In addition to sending the form to
the dress(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Pelt ds Amount: 11h completion of well construction to the county health department of the county
wher constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016