GW1-2022-06810_Well Construction - GW1_20220718

WELL CONSTRUCTION RECORD (GW-1) Fo7 Internal Use Only: Print Form
1.Well Contractor Information:
W 1 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
y�( (�,,�tl ft. ft.
ITV c_ t 3Ot ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mold cased wells OR LINER if a livable
e IV0 ` t^ -nic-, FFROMTO DIAMETER THICKNESS MATERIAL
t ' L ft. F n�/ ft. in. Z5 ro� N[C Company Name mar
ER CASING OR TUBING eothermal closed-loo2.Well Construction Permit#• - W TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County, tale,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17,SCREEN
FRO V1 TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Re'sidential
sidential Water Supply(single) ft. ft. in.
Industrial/Commercial Water Supply(shared) 18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring DRecovery
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SANDIGRAVEL PACK if a ticable
Aquifer Storage and Recovery n Salinity Barrier FRO] TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.1 RILLING LOG attach additional sheets if necessary)
FRO TO DESCRIPTION(color,hardness,sail/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) rl Other(explain under#21 Remarks) ft. r ft.
CIAQ
4.Date Well(s)Completed: 1� Well ID# b !fit 1 ft. f ft. pip
O c
Sa.Well Location:
CT
ft.
J A50n a kAef LA` q KE_f ft. ft.
Facility/O/�wner/N�ammee [� f Facility ID#(if
,`applicable) ft. ft.
�r--A CO D R 6 1 L 1 1 Z P ,�l C_
Physical Address,City,and Zip
ft. ft.
W Co 53 4 Q 4 21.1 EMARKS
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.C rtification:
N W — —ap
6.Is(are)the well( Permanent or Temporary Cyo
i of Certified Well Contraclor Date
yyy {{{,,, y si ing 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 No ith A 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 n explain the nature of tha this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.S'a 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.
drilled: C SUBMITTAL INSTRUCTIONS
r
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 ifdWerent(example-3@200'and 2@100') constiuction to the following:
l
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"�++" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: (in.) 24b. or Injection Wells: In addition to sending the form to the address in 24a
t 12.Well construction method: /t /7/� above, also submit one copy of this form within 30 days of completion of well
)�Z/ �-f(i.e.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
L-lf\
13a.Yield(gpm) I L.) le-Ale-6-Method of test: I �Z 24c. or Water Su l &In'ection Wells: In addition to sending the form to
V rthe dress(es) above, also submit one copy of this form within 30 days of
=
13b.Disinfection type: Amount: �� comp etion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Qua ity-Division of Water Resources Revised 2-22-2016