GW1-2022-08046_Well Construction - GW1_20220829

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Informatiion[:,
FROM
WATER TO DESCRIPTION
Well Contractor Name '�t-
3 d 2 t't/-AT
NC Well Contractor Certification Number :IS.-OUTER CASING foc niolti.cased avells)OR LINER(if a licable
1 q 2�� /S J✓,C FROM TO I DIAMETER THICKNESS/ MATEMAL
t /
Company Name I6.INNER CASING OR TUBING(geothermal 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.[Industrial/Commercial
Supply Well: FROM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
cultural h M icipal/Public 0 ft. ft. in.
thermal(Heating/Cooling Supply) esidential Water Supply(single) et. et. in•
Residential Water Supply(shared) 18.GROUT
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft.
Monitoring i_ Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remedjation
19.5AND/GRAVEL PACK Cif a IiGible
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft• ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG(attach additional sheets if necessary)'
Geothermal(Heating/Cooling Return) - Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soiVmek type,grain size,eta)
nn ft. 7 ft. DV G'
1(2-22WellID# r13� /^ ft. ft.
4.Date Well(s)Completed: - �('� L 1401 C
5a.Well �Location• ft. ft. ��
k f/� �t S ft. ft. T
Facility/Owner Name I G Facility ID#(if appliiccaabbll/e) / ft. ft. (7
f907 Gl�,-/ C Zo,g �� 1-/,rr.e-IlC
Physical Address,City,and Zip 7-7,C 1( ft. ft. J f
022
'21.REMARKS:' o.
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/loag is sufficient) 22.Certification:
N W
6.Is(are)the well(s) 'ernmrtent or OTemporary Signature of Certifi el ontractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or K.- with 15A NCAC 02C.0100 or 15A 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: (D t (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: Z� A) 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: ro (in.) 24b.For Injection 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,Undeiground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ," (—Agol ) Method of test: t,,n 06,r7i 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: Cif», 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