GW1-2022-08313_Well Construction - GW1_20220517

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: D
:14:WATER ZONES. ..
Well Contractor Name FROM TO DES RIPTION
p ft. 5 � It.
V" ft. ft.
NC Well Contractor Certification Number ^ 1�` 15.'OUTEWCASING(for.multFcased'ivells ORLINEW(if a 7lcahle
n 1` 1 \\�� ` Iy\ L FROM TO DIAMETER THICKNESS MATERIAL
�% y` �/, 1 ` _ , -.- ft. I P', ft. I /a in. 1 S(%,Ll l) Pvc,
Company Name
a ��� �®�D�� 16.INNER'CASING OR TUBING' 'eothcrmado l sed=loo .. .�.
2.Well Construction Permit#: w FROM I TO DIAMETER I THICKNESS I 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.SCREEN...'?
Water Supply Well:
r .. ..
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [DMunicipal/Public 91 ft. 31 ft. in- c \a su'., o PvV
Geothermal(Heating/Cooling Supply) EResidential
esidential Water Supply(single) tft. ft. in.
_, Industrial/Commercial Water Supply(shared)
_ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. p it. h n� r
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge EJGroundwater Remediation
19.SAND/GRAVEL PACK(lf a' livable) "
(- Aquifer Storage and Recovery MISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_Aquifer Test ryfftt OStormwater Drainage
Experimental Technology QlSubsidence Control
ft.
Geothermal(Closed Loop) ElITracer 20:DRILLING'LOG:(attricG addltioii ilaheets itriccessu'
FROM TO DESCRIPTION(color,hardness,sail/rock ty e, rain size,etc.)
RGeothermal(Heating/Cooling Return) I Other(explain under#21 Remarks) ft. ft.
1
4.Date Well(s)Completed: ® Well ID# ft. ft. —sam l , Q
5a.Well Locccation:,�( (y ` ,, _p �+ /�
('1A V V`1\VCLM� ft. ft. Sa 6 l..(3—
FacilnerName Facility ID#(ifapplicable) 9-1 ft. ft. � G
ft. ft.
Physical Address,City,and Zip Q (� h(� ft. ft.
O yiq Vb Om21.REMARK -
County Parcel Identification No.(PIN) 2022
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: ` 5�t"ti,tfir.5I I0401 r7,j
t';+) 5co ,ao3 N �18C) 33, �&I W
5 - -�
6.Is(are)the well(s)OPermanent or E3Temporary Signature of ertified Well qntractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ]Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consinrcrion Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy ojthis 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: 1 (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@I00� construction to the following:
10.Static water level below top of casing: I t (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: [V (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
n \12.Well construction method: above, also submit one copy of this form within 30 days of completion of well
i�Ul (�
(i.e.auger,rotary,cable,direct push,etc.).) construction to the following:
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: Ups 24c.For Water Supply&Injection Wells: In addition to sending the form to
1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type. Amount: completion of well construction!to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016