GW1-2022-08294_Well Construction - GW1_20220517

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
1 a V W U � 1 1 V� V' �Y 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a livable)
+ C FROM TO DIAMETER THICKNESS MATERIAL
\1 1 J W e' 1 ���\�I�0� -- - - ` rt. `�o� ft. in. t�O �L
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: " '" " r ubt:>Ia FROM TO DIAMETER 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public p,3t't. alp ft. 'n'
❑Geothermal(Heating/Cooling Supply) 'idential Water Supply(single) ft. ft. in.
❑hidustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft' Oft. 2 t/Z b -
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Storinwater Drainage A D ft. t. � ,,{
❑Experimental Technology El Subsidence Control ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRH'TION(color,hardness,soil/rock type,gain size,etc.)
D ft. ft. sa✓1�1
4.Date Well(s)Completed:� Well ID# ft. et. Sq n(,�` G 0.
5a.Well Location:
IM�YtP�n-Ti�.� rt. rt. C 1
n
Facility Owner Name ` Facility ID#(if appllii(cable) ^ft. ft. A r ` �A
h
Physical Address,City,and Zip ft.
S��,rf,nra�r• p�✓� Ol (� �1 O�� 21.REMARKS County Parcel IdentificationNo.(PIN) MAY Z
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t _
(ifwell field,one lat/long is sufficient) 22.Certification: ,,�. ,._R,vwv~I ?!��'�6.j'`,"%%31J`:I 1
Ic,q N -is t 1),IC Cl
r� W
' ct.ww rt/ oZ a�a'
6.Is(are)the well(s): 69�rmanent or ❑Temporary Signature ofCertifi well Contractor Date
JV By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or V0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information an explain the nature of the 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 construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: oC (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
10.Static water level below top of casing: L� 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.)
Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rn.UA zx'� 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
t Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:�O1�-
13b.Disinfection type: 1 t"1 Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018