GW1-2022-06811_Well Construction - GW1_20220718

Form
WELL CONSTRUCTION RECORD(GW-1) I F r Internal Use Only: Print
1.`ell CAontraacctor Information:l c C
i ( l 1 1 7 14.WATER ZONES
Well Contractor Name
FR M TO DESCRIPTION
M L _�c, + ft. ft.
\1�Y��" ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if a cable)
�O �-j l 1 I ""' C FROM TO DIAMETER THICKNESS MATERIAL
Com an Name G- 11 it. /„ /ft. ,o6 in. � �/r
P Y lY [ 1.
16.INNER CASING OR TUBING(geothermal closed-looDl
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(t.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.3CREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public it. ft, in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18. ROUT
Irri ation FRC M I TO ATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19. AND/GRAVEL PACK if a licable
Aquifer Storage and Recovery 0 Salinity Barrier FR M TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20. KILLING LOG attach additional sheets if necessa
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) FRI M To Sc TION(color,hardness,sail/rock type,grain size,etc.)
q—� q� ft.
pp � ft.
4.Date Well(s)Completed: 'L —O'oc Well ID# be f ft. r ft. c Q
ell �tion: ft. t�J0 ft.
r (+ ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
e ft. ft.
Phy 4cal dress,City,and Zip �� ft. ft.
�� � . 451bD 54�+�GL.7 Q� 6 21. MARKS
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 ertification:
1
N W ^rCr
6.Is(are)the weil(s)y�(jlPermanent or Temporary SiT14
f Certified Well Contractor Date
L� By 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 o wiCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information nd explain the nature ofthe o record 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:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You i nay use the back of this page to provide additional well site details or well
construction,Tly 1 GW-1 is needed. Indicate TOTAL NUMBER of wells cons ction details. You may also attach additional pages if necessary.
drilled: /r,^ SUB ITTAL INSTRUCTIONS
9.Total well depth below land surface: t�6b (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) const uction to the following:
----------------
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
11.Borehole diameter: LQ (in.) 24b. or Injection Wells: In addition to sending the form to the address in 24a
r 12.Well construction method: above,also submit one copy of this form within 30 days of completion of well
!j� ti ��(i.e.auger,rotary,cable,direct push,etc.) f
constction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 11<6 Method of test: T'C()` 24c.For Water Supyly&Injection 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: C-156 completion of well construction to the county health department of the county
whert constructed.
Form GW-1 North Carolina Department of Environmental Qua ity-Division of Water Resources Revised 2-22-2016