GW1-2022-07887_Well Construction - GW1_20220822

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
cContractor
I�nfor�mation: Iz
_/ L'1�_�)/►�D, 1'<Ao 1 .WATER ZONES
Well Contractor Name F OM TO I DESCRIPTION
NC Well Contractor Certification Number
1 .OUTER CASING for multi-cased wells OR LINER if a licabte
e ` T F OM TO DIAMETER THICKNESS MATERIAL
ft. ft. `�js
Company Name
16 INNER CASING OR TUBING(geothermal closed40013)
2.Well Construction Permit#: __Lp OM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Counht State,Variance,etc.) Ict. t. 5 in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17 SCREEN
FROM 1.0 DIAMETER SLOT SIZE 'THICKNESS MATERIAL
NAgricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) VResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18 GROUT
hTigation FR M TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 0 r ft. Q a C
Monitoring oRecovely ft. ft. Fim
Injection
Aquife W :
rRecha ft ft
19.SAND/GRAVEL PACK(if a licable)
Aquifer Storage and Recovery Salinity Barrier FR M To I MATERIAL I EMPLACEMENT METHOD
Aquifer Test oStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20,DRILLING LOG(attach additional sheets if necessary)
FROM TO _DESCRIPTION color,hardness,soiltrock type,main size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. 6 ft.
4.Date Well(s)Completed..'
ompleted:i Well ID# ft. "'. L
ell Lod'
e eU
fL ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
�
hysical Add e
` ss,City,and Zip ft. ft.
p S'^ Lee- 21. MARKS
C_ouritty 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:
t
N W
6.Is(are)the well(s) Bermanent or Temporary Sig tune of Certified Wdl Contractor ate
�� Xa ,,
By 'ning this form,I herelry certify that the xell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes oo with 5A NC.4C 02C.0100 or•15A NC4C 02C.0200 Well Construction Standards and that a
Ifthis is a repairfill out known well constructiwr ta/ormatiolan the nature of the copy f this record has been provided to fire well owner.
repair raider#21 remarks section or on the back of this form.
23. ite diagram or additional well details:
S.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-I is needed. Indicate TOTAL NUMBER of wells consi ruction details. You may also attach additional pages if necessary.
drilled: I SUB ITTAL INSTRUCTIONS
9.Total well depth below land surface: 9 rco (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ivells list all depths if different(example-3@200'and Nb,,100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
!f water level is above casing,use//"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: LSL (in.) 24b.IFor Injection Wells: In addition to sending the font to the address in 24a
abov , also submit one copy of this form within 30 days of completion of well
12.Well construction method: j cons ction to the following:
e[e
(i.e.auger,[rotary,cable,direct push, )
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: i1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ��_ Method of test: 24c.1~or Water Sum&& Injection Wells: In addition to sending the form to
�(
the address(es) above, also submit one copy of this fort within 30 days of
13b.Disinfection type:" Amount:9n 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