GW1-2022-08240_Well Construction - GW1_20220829

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well
Contractor 1orm/�ationn:
/ h� ) 1 T f r `Z�Q I�� 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
u (j� ft. ft.
l 5 Z L� c ft. ft.
NC Well Contractor Certification Number AS;OUTER CASING(for niniti caiedwells)OR LINER Ira Ilcable `
f� 1� 1 7 14 E LI C FROM TO DIAMETER MCKNESSr MATERIAL
( 1 l J rt. T ft. 1
1_I in. J C LI
Company Name
�� FROM
INNER CASING OR TUBING euthermal closed-loo
2.Well Construction Permit 8: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i e.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13MunicipaUPublic G ft. ft. in.
I Geothermal(Heating/Cooling Supply) Dkesidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) I&GROUT
lrri atlon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. It. I fC Pr P o
Monitoring i. Recovery ft. ft.
Injection Well:
ft. et.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a Gicable
- Aquifer Storage and Recovery nSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E]Stormwater Drainage ft. ft.
i Experimental Technology OSubsidence Control ft. ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
I_ Geothermal(HeatinglCooling Return) 0 Other(explain under#21 Remarks) FROM To DESCRIPTION(color,bnnlness,solvrodk etc-
ft. ft. _
. '
4.Date Well(s)Completed: ' _cV Well ID# [t.
Sa.Well Location: ft. ft. AUG
R A 2 T c I-smu ft. ft.
ft. ft. tn�i 5=L.•1 : i s :;a: r7li
Facility/Owner Name Facility ID#(if applicable)
1 Sl/1 1 fR D T-gi�L L- M, ft. ft.
Physical Address,City,and Zip R' R'
T e R 50N 21.REMARKS
1; _ eR
County Parcel Identification No.(PII�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: O..r 6 Z
(if well field,one lat/long is sufficient) 22.Certification:
2(9, 514 q,,5 L1,e) N ?�I SOD A I w yC� - — I —
6.Is(are)the well(s)[9Permanent or OTempolary Signature of Certified ell Contractor ate
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: [D�es or J3No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 lVell Construction Standards and that a
If this is a repair,fill out Mown well construction information and explain the nature of the copy of this record has been provided to tire 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 I GW-I 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 (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@a 200'and 2@100) construction to the following:
10.Static water level below top of casing: 25 (ft) 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: /� (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: R C)T RR U 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: � n 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) (
Method of test: 1 A P) 1_ 24c.For Water Supply&Iniecifion 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: 14 T H Amount: 7 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