GW1-2022-08318_Well Construction - GW1_20220829

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
./�ASQ �J'� 14..WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
C ft. ft.
J et, it.
NC Well Contractor Certification Number 18:OUTER CASING Col muiti cased wells OR LDVEA'tin Doable
_��C►e _I 1��, �� �R t FROM To DIAMETER THICKNESS MATERIAL
I 1'C, •V ft. ft. in.
Company Name IC INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(le.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM SCREEN
TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public U ft. ft. in.
Geothermal(Heating/Cooling Supply) &esidential Water Supply(single) ft. ft.
Industrial/Commercial DResidential Water Supply(shared) ls.GROUT
: Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&A61ouNT
Non-Water Supply Well: i ft. ft-
Monitoring L Recovery ft. ft.
Injection Well:
tt. Ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK tf a liLable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERMLL I EMPLAC04ENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control it• ft• � "—_�
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if
I Geothermal eating/Cooling Return) FlOther(explain under#21 Remarks) FROM To DESCRIPTION(mlor,hardness soNmck etc.
ft. ft.
4.Date Well(s)Completed: Well ID# -
5a.Well Location:
aQ U 1"QrMIP`Q, ft. ft. AU
Facility/Owner Name Facility ID#(if applicable) ft. ft.
••�/ `' ` {� 1 _ (� p —j ft. ft fln�rr i i i l r'r�; u;:'•.3 !kill
/ �� 01��'YN �rt QUA lv� I Ali r�/-71
Physical Address,City,and Zip ft. ft.
21.RRMAM
County Parcel Identification No.(PIN) NotS e 1c
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1 L r(
(if well field,one]at/long is sufficient) ✓J p 0 22.Certification:
J10D O�t q7if N /0 ��� t �d /t W
--
6.Is(are)the well(s) —ent or OTemporary Signture of Certified Well Contractor VIVII, Date
;�y� By signing this form,I hereby certiB that "well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: b�" 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 and explain the nature of the copy 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 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: (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@100) 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 r+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. y (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: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Undeigroand Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Iniecdon 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: Scompletion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016