GW1-2022-06812_Well Construction - GW1_20220718

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WELL CONSTRUCTION RECORD(GW-1) Fo Internal Use Only:
1.Well Contractor Information:
L men R OO ���r 1� R ATER ZONES
FROM TO DESCRIPTION
Well Contractor
Name /�
7
L y C- V lam• a 4 0 4 —_
NC Well Contractor Certification Number 15.C OUTER CASING for multi cased welts OR LINER if a Hcable
C c FRO TO DIAMETER THICKNESS MATERIAL
t i ft. t ft. t aY in. to Y c—
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: FRO d TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. 1
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) in•
Industrial/Commercial nResidential Water Supply(shared) 18.GROUT
hTl ation FRO VI TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. o
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge nGroundwater Remediation
19.6 AND/GRAVEL PACK if a licahle
Aquifer Storage and Recovery 0 Salinity Barrier FRO TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) []Tracer 20.1 KILLING LOG attach additional sheets Knecessa
FRO TO DESCRIPTION(color,hardness,soillrock e, rain size,etc.)
Geothermal(Heating/Coolin
g
Retum) Other(explain under#21 Remarks)
4.Date Well(s)Completed: 1' 13_9,P Well ID# t ft. ' AOI ft. bhothL
5a.Well Location: ft. JrOrft rQA;f1i
C 5 0
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Kir
ft. ft.
I �
nP sicalP sical Add��rejjss,Ci``tyCC,and Zip / �—
C.ItI_JI 10 P_ 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. ertifieation•
6.Is(are)the well(s) permanent or OTemporary Si ure of Certified Well Contractor Date
By ij Bing 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 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 informationlandVxplain the nature of the copy ofthis 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:
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: l SUB ITTAL INSTRUCTIONS
9.Total well depth below land surface: 50 (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@100') consi ruction to the following:
10.Static water level below top of casing: AQQ \" (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: LP (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
e abov,also submit one copy of this form within 30 days of completion of well
12.Well construction method e tc.) cons ruction 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) 4 Z Method of test: Arc- 24c.For Water Supiply&Iniection Wells: In addition to sending the form to
theaddress(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: �Q Amount: e3b completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quility-Division of Water Resources Revised 2-22-2016