GW1-2022-08322_Well Construction - GW1_20220518

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
11 � r 14.WATER ZONES
WellContractor Name FROM TO DESCRIPTION
LAIft. 5z f L ✓a SapteP
ft. it.
i
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(ff a livable)
\�(`\��ty&' �" ` 6Vk FROM TO DIAMETER THICKNESS MATERIAL
o p `OLJ yV y t- ft. L4 I ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: w�t�I - D 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 (_]I ft. 50 fL in. q1` ;(t_, (0 �((•�
❑Geothermal(Heating/Cooling Supply) a idential Water Supply(single) 1 ft. ft. in.
VV 1 at•fl`i
❑Industrial/Commercial Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ao ft. Bmm'6 ) b
❑Monitoring ❑Recovery ft. ft.
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 ❑Stormwater Drainage O ft. o ft. #+ G�
❑Experimental Technology El Subsidence Control ft. ft.
❑Geothermal(Closed Loop) []Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,gain size,etc.)
❑Geothermal(Heating/Cooling Return) []Other(explain under#21 Remarks)
4.Date Well(s)Completed: I -"1 21 Well ID# ft. 1 ft. �q rt A L(/
a
5a.Well Location: e jA C a
et � Id
lih I� O > ra Ct
Facility/OwnerName r, p Facility ID#(if applicable) ft. ft.
! &U U t„ a`i`+T. ft. ft.
Physical Addres ity,and Zip ft. ft.
50i i\n�� DA b�6 9$A 5�� 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) 22.Certification I ftkya
'R>S .a © I i OR J N t Iq-1 W
6.Is(are)the well(s)• Permanent or ❑Temporary Signature ofCertifi well Contractor Date
X" 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 XN
0 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 and explain tine 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 1 GW-I 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: 50 (ft.)
For multiple wells list all depths ifeli ferent(example-3@200'and 2@100D Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
If Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/f water level is above casing,use"+"
11.Borehole diameter: tY (in,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rn« VN 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
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount: 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resouri es Revised 6-6-2018