GW1-2022-07140_Well Construction - GW1_20220804

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
.-J7•�1 n � a.wATERZUNES-.:- :.;__ _ -
mom TO DESCRIPTION
Well Contractor Name
• ft. ft.
_JO
NC Well Contractor Certification Number `A5.OUTER'CASING(foe eluiti cased welts)OR,LINER'tLa`lii�ble
FROM TO DIAMETER THICraVESSMATERIAL
�l0.�C.� , LA B ✓ n ft. fL tn.
Company Name v
`16.INNERCASING:ORTQBING'•(eotliermalclosed-loo
2.Well Construction Permit#: K)- I FROM I TO I DIAMETER I THICKNESS I MATERIAL Y
List all applicable well construction permits(i e.UIC,County,State,Variance,etc.) ft. ft, in•
3.Well Use(check well use): ft. ft. I in.
I
upply Well: F FROM�E TO DUMETER SLOTSIZE TInCKNEss MATERIA►.Agricultural Icrpal/Public ft. ft.Geothermal(Reating/Cooling Supply) esidential Water Supply(single) g ft in.
ndustrial/Commercial Residential Water Su 1 sharedPPY( ) °•18:GROUT..rrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
:Monitoring Recovery ft. ft. a
Injection Well: ft. ft.
Aquifer Recharge ElGroundwater Remediation _
1.:19.$AND/GRAOEi.PACK ffa"vllcable)_. .
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStorinwater Drainage ft. ft.
I Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLINGLOG(attach additlorielsheetsifn
FROM TO DESCRIPTION colon hardness,soil/mck size,eta)
-Geothermal(Heatin Cooling Return) !_ Other(explain under#21 Remarks) PZ ft. Al
4.Date Well(s)Completed: I �-Well ID# ft- ft.
y .
Sa.Well Location: ft. ACO
t �// ( ft. ft. C
Facility/Owner Name Facility ID#(if applicably ft. ft. 4 ,
Physical Address,City,and Zip ft. ft. rA
?21.REMARKSIle
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County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minntes(seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W ZY- -7, 1 S?- lL
6.Is(are)the well(s)"cut ern cut or Temporary Si of Certi a ell ctor Date
4 signing this form.I hereby certify,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Eyes or No with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this 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: , 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 different(example-3(200'and 2@100) construction 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"+" 1 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 /$ (in) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
1 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: I& 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: O Wn rs4. .For Water Supply&Iniection 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: 3® thkn tm 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