GW1-2022-08317_Well Construction - GW1_20220517

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information.-
t�—y 1 V V 111 "� 14 WATER ZONES
We11Con[ractorName FROM TO DESCRIPTION
o�payft. `6�✓2C� ft.
ft. ft.
NC Well Contractor Certification Number 15r OUTER CASING for i ult cuscd wells OR LINER(if aHC61c"
rti`�` O��tC Q� 11 It FROM TO DIAMETER TffiCKNESS MATERIAL
ft. �QQft. in. 599 a
Company Name 1 O
''16.
j a INNER CASING OR TUBING,'eot6crntuPclosed-loo
2.Well Construction Permit#: C/�v 1 1 ..! �-D4 FROM To I 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: M.SCREEK,';
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:,]Agricultural i_1 Municipal/Public ft. ft. in.
i Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ft. ft. in.
IndustriaUCommercial []]Residential Water Supply(shared) 18.GROUT:...:
7.
_ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. ] O
'
WL Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
_ Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(Ifa"'lidable)'.
Aquifer Storage and Recovery MI Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStonnwater Drainage ft. ft.
Experimental Technology Ell Subsidence Control
_ Geothermal(Closed Loop) QlTracer 20'.DRILLING LOG.(:i tucli additional s1kets if nece'ssuiy)'.
FROM TO DES RiPTION(color,hardness,saillrock type, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
ft. ft.1
_i d
q Well ID# ft. oC ft. `�
4.Date Well(s)Completed: q n u
5a.��Wl���e++lll�Location: �ptmra
� ft. 1$ ft. i
\N'Nu.1 1 'IN UTI� 1 �a Z.a� ,) `g_f t. �ft: (�-�kL C l
Facility/Owner Name FacilitylD#(ifapplicable) S
3%1 .0Lk tr PI eft.
Physical Address,City,and Zip ft.21.REOMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3q° 51 IC1I N IS" 50 OQa w y
6.Is(are)the well(s) ermanent or ]®]Temporary Signature o696rtificd Well Intraefor 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: rJYes or Wo with 1 SA 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 a d 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
r
9.Total well depth below land surface: r; (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@100D construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use q"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1 Q (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
t� above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: i'Y�U� �� I r fGlkU 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) I Method of test: D t n 24c.For Water Supply&Iniection 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: , �, completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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