GW1-2022-07461_Well Construction - GW1_20220810

Print Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
�' [-3G+j�G�� !✓fit 4 ��,y!/ 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name -_
ft.
rt. ".
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a licable)
_ FROM TO DIAi\'IETF:R THICKNESS MATFRIAI.
/0..� �•C� /J r,• //per�i ff. ft. in.
Company Name f, �! � X��I ) 16.INNER CASING OR TUBING eothermat closed-lop
2.Well Construction Permit#: ! f' /� / / / / A�./�✓ r�� FROM TO DIAMETER THICKNESS MATERIAh
List all applicable+cell consnvc•tion per ants 0 c.UIC.Coannt State. I Fiance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) ft. ft. in.
IndustriaUCommercial DResidential Water Supply(shared) 18.GROUT
11T1 anon � c'�
' tl, FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: "° ft. tt.
onitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groun w t>} 4t�metd4aeis g U
I Gi t grr�•��? 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery [3Salinity BarrieE)%A,0,t30G FROM TO MATERIAL F.MPLACF.MENTMETHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soittrock t e, rain size,etc.
Geothermal(Healing/Cooling Return) Other(explain under tt21 Remarks) �•-
L� C Xt=.
4.Date Wells Completed: 7 z Well ID# CJ p ft- '3-S- ft-
5a.Well Location: / .5 H. [ ft. (A?r., [j •-�:' / �y;.s, v r^c<<<-
J""!A!-/'Y){�I� i�l..l I�ry•t `.�L'�'1 C ,5'"ft-
Facility/Owner
Name / Facility ID#(il'applicable)
(/
3 c 4 �/ 1�•,(/� L e)e: ru f 0, d"C/� R. ft.
Physical Address,City,and Zip
/7 21.REMARKS
County Parcel Identification No.(PIN) I C I- -t r' r Z 1411y��1tv n:rLrv�(IlNC� .Cu' ft�'(�,C Ce'2r', t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ll��� re m r
(if well field,one tat/long is sufficient) ) 22.Certification LU �i r" f�Y , C.
3 5_ &.3 2.o y•7�3 N a YO, 73 C•-3 C� t l W I ^ Jt
6.Is(are)the well(s)OPermanent or WTemporary Signature ol'Certified Well Contractor Yw Date
By signing this/in'tn.I herehr e"Illi�that the welllc)was(mere)constructed in accordance
7.Is this a repair to an existing well: [3Yes or JoNo vith 15.4 NCAC 02C.010n ar 15A NCAC 02C.0200 Nell Construction Standards and that a
lfthis is a repair,fill out known mell construction information and explain the natm a oJthe cope of this recarrl has been provided to die well owner.
repair under#21 renmrks section or an the back o/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 I 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: �CJ (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple+cells list all depths if different(example-3 6200'and 2@c/00') construction l0 the following:
10.Static water level below top of casing: . (ft.) Division of Water Resources,Information Processing Unit,
If++'aier level is above easing..use-4- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection 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: �•�'✓✓% C 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: 24c. For Water Supply&Iniectfion 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: completion of well construction t! the county health department of the county
where constructed.
Fomi GW-I North Carolina Department of Gm'ironmr:�' Division of water Resources Revised 2-22-2016