GW1-2022-08291_Well Construction - GW1_20220517

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Itm1 � —S v 14,WATER ZONES
Well Contractor Naa pe FROM TO DESCRIPTION
2
ft. J ft.
NC Well Contractor Certification Number _ 1 . 15.OUTER CASING(for multi-cased:wells)OR LINER(if a licable
P D�f 111 1 FROM TO DIAMETER THICKNESS MATERIAL
[11f11N VV l 1 ` ( fL NaY1 fL in. abLk
Company Name 1
v� 16.INNER CASING OR TUBING dothern al'closed-loo
2.Well Construction Permit#: ,✓ a1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. it. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:)Agricultural E]Municipal/Public ft 31 ft• O� in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in. 'L
Industrial/Commercial Residential Water Supply(shared) 18.GROUT,
h1i ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. t o ft. 1/t'f1�0>n� Lk
Monitoring DRecover-y
Injection Well:
ft. ft.
(_ Aquifer Recharge EJ Groundwater Remediation
.19.SAND/GRAVEL PACK(if applicable),
3- Aquifer Storage and Recovery Ell Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:)Aquifer Test OStonnwater Drainage
ft. ft s
Experimental Technology []ISubsidence Control ft. ft.
D Geothermal(Closed Loop) ITracer 20.DRILLING LOG(attach additl6fial sheets if
FROM TO DESCRIPTION(color,hardness,soillrock type, rain size,etc)
_ Geothermal(Heating/Cooling Return) IOther(explain under#21 Remarks) ft. ft. -Vz j
4.Date Well(s)Completed: Well ID# 91
ft. ft. Q..hd Ct
Sa.Well Location: co ft. ft. ovaoAc
_W�v G"
ft. ft. C `'Y'\\�
Facility/O(vner Name Facility ID#(if applicable) 9-)ft. 3 ft. COO`t
-V, n CAL
LI j 1 u �V�1�1 -101 J ipoy)n ft. ft. �
Physical Address,City,and Zip ft. ft.
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) t� 22.Certification
35° JLe. (q�( N I� a Q i Q-) W
6.Is(are)the well(s) Permanent or Temporary Signature ofVertTfied Well qntractor 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: DYes or No 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 n explain the nature of the copy of this record has been provided to the well owner.
repair under 421 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: 2 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3yy@200'and 2@100� construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
AA 1 above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: �GI �,o}anA 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&Injection Wells: In addition to sending the form to
r, the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: ,/`i �Y�� completion of well construction Ito the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016