GW1-2022-06821_Well Construction - GW1_20220725

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
well Contractor Information: C
14.WATER ZONES
+ FROM TO DESCRIPTION
Well Contractor O-rNamen�- ft. ft.
I V�V�l c- 0 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a #cable
`( ( [ FROM TO DIAMETER THI
CKNESS MATERIAL
10 'r
b l 60 n eA L d�l 1 l L n G �Y L © ft. i I(% ft. ;6 in. �51)r-;LjC
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER I 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.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared) 18. ROUT
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 1 ft. rd
Monitoring Recovery fi• fi
Injection Well: ft. ft.
Aquifer Recharge rl Groundwater Remediation 19.SAND/GRAVEL PACK if app#cable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test n Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets N necessary)
FROM TO DESCRIPTION(color,hardness,soUt ck e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)]
4.Date Well(s)Completed: Well ID# 91r,ft. ft.
ft. ft.
5a.Well Location:
lC IA.t7t K CA 1 V Gn`lJ
Facility/Owner Name �( f Facility ID#(if applicable)
V_n6 , 1`! )�f I 1 I (J 7
Physical Address,City,and ip
p -Rb b� 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.Certification:
W l
N - '12
6.Is(are)the welt(s)KP
ermanent or Temporary
JWi
e of Certified Well Contractor Date
ng 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 NCAC 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 ofthehis record has beers provided to the well owner.
repair under#21 remarks section or on the back ofthisform. 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: ��RRrr t SUBMITTAL INSTRUCTIONS
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 if dierent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: L DC) (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: 0 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Cog 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) e2 Method of test: 1N 17Z _ 24c.For Water Supply&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�� completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016