GW1-2022-08366_Well Construction - GW1_20220517

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.W [Ctractor Information:
r 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. a L,ft. tAA Sex K
��V`�� I•J ft. ft.
NC�Well Contractor iC�eertifiyation�Nuummb�er d 15.OUTER CASING(for multi-cased wells)OR LINER(if a livable)
FRO
,/ I{v t 1 `C ' :5 �1.er 1\ I l i- X -if-IM fL TO DIAMETER in. THICKNESSMATERIAL
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. fL in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipa"ublic 01 `ft- a t. in- sul 40 pvC-,
❑Geothermal(Heating/Cooling Supply) >6sidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. • aft.
❑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 ❑Stormwater Drainage ft, n ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
1 0 ft. o, ft. -kas Q 1
4.Date Well(s)Completed: V�J'tR?-VVell ID# ft. ft. -51 1 nd Oa
5a.Well Location:
S O- to �° , ft. AV 14-ekA
,
Facility/Owner Name Facility ID#(if applicable) ft. ft.
b o n n W, z9 734
Physical Address,City,and Zip
\^L I ob�v«'N 21.REMARKS MAY 17 `
County Parcel Identification No.(PIN)i3(J
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification:
r� y -, ,� p
N 4A W r 1� �iC7c(�( �.✓M�/ ` ID d
J
6.Is(are)the well(s)• Aermanent or ❑Temporary Signature ofCe ' ed Well Contr ctor Date
s�r By signing this form,l hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 00 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 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: ��O (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')
p 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft*) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"II --
11.Borehole diameter: 1 (in,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: V8 J- 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
13a.Yield(gpm) Method of test:
Permit Program, 1611 MSC,Raleigh,NC 27699-1 6 1 1
��I 'l1\D 1'(�
13b.Disinfection type: t-i�Ci Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018