GW1-2022-07966_Well Construction - GW1_20220829

WELL CONSTRUCTION RECORD(GW-1) For nternal Use Only: Print Form
1.Well Contractor Information:
1\ , tJ� 1 t Jli 1 1 14.WATER ZONES
Well Contractor Name FROrkil I TO I DESCRIPTION
MC— V_ , o _
NC Well Contractor Certification Number 15.ObTER CASING for multi-cased wells OR LINER if a licable
C '�j i ' 1 FROM TO DIAMETER THICKNESS MATERIAL
Company Name 4 ft. ft. 1 in. ©r—� F7 1/C
16.I NER CASING OR TURING eothermal closed-loo !'
2.Well Construction Permit#: FRONI I TO DIAMETER THICKNESS MATERIAL
List all applicable well conshruction permits(i.e.CIC,Carty,State,Variance,etc.) IL ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.S REEN
FRO31 I TO DIAMETER SLOTSIZE 'THICKNESS MATERIAL
Agricultural ®Municipal/Public ft, ft, in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
`�J-sR ft. ft. in.
Industrial/Commercial -pesidential Water Supply(shared) 18. ROUT
lrri ation FRO) 1 TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft, 001 ft. O f— O rQ,y,'
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19. NDIGRAVELPACK 1'a licable)
Aquifer Storage and Recovery Salinity Barrier FR 1 TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test E)Stomtwater•Drainage ft. ft.
Experimental Technology nSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20. RILLING LOG attach additional sheets if necessa
Geothermal(Heating/Cooling Return) r3 Other(explain under#21 Remarks) FRI 1 TO DESCRIPTION(color,hardness,soiltrock type.grain size,etc.)
ft. t ft. Ked (21 4Q
4.Date Well(s)Completed: w9 Well ID# It. 11146 ft. C C
ll Location:
I ft. ft.
_LL
(,no C
p G ft. ft.
Facility/OOwnnelrName Facility ID#(ifapplicable) ft. ft.
�'�&S6.01) ^
Physical Address,City,and Zip
1 \n e t`i „ e rc es 21. EMARKS
County 1 �� Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/Ions is sufficient) 22 Certification:
6.Is(are)the well(s) ermanent or Temporary Si , ure ot'Certitied Wcll Contractor Date
r
� By s'ring this,Jbrnn.I hereby certi/i•that the ur1L(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or No with SA NCAC 02C.0100 nr 15A NC.AC 02C.0200 Well Construction Standards and that a
Ifthis is a repair.,Jrll out known well construction itJarntanimtCau explain the nature gfihe (this record has been provided to the well owner.
repair under#21 remarks section or on the back of this farm.
23. to diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You nay 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 cons ruction details. You may also attach additional pages if necessary.
drilled: SU ITTAL INSTRUCTIONS
9.Total well depth below land surface: U CL� (ft.) 24a. For All Wells: Submit this torn within 30 days of completion of well
For nudliple wells list all depths if different(example-3Q200'and 2(&100') con ction to the following:
10.Static water level below top of casing: CJU (ft.) Division of Water Resources,Information Processing Unit,
If writer level is ahove Casing,use +^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: p(in.) � ) 24b or Injection Wells: in addition to sending the form to the address in 24a
12.Well construction method: f��taC/ abo ,also submit one copy of this form within 30 days of completion of well
con I
ction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
#vision of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
�` C/�j
13a.Yield(gpm) TV Method of test: 1!G, 24c. or Water Suably&Iniection Wells: In addition to sending the form to
A the aodress(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: O 11((S6 Amount: completion of well construction to the county health department of the county
whe rf constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016