GW1-2022-08372_Well Construction - GW1_20220518

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:t_a
I m ,1�� (�r 14,'WATER ZONES.;:_.
Well ContracttoornName FROM TO DESCRIPTION
ft. 3-, ft.
ft. ft.
NC Well Contractor Certification Number 15:OUTER;CASING for:niulti cusbd•wells OR LINER(IESSfa'llcable
1 1l FROM TO DIAMETERKN MATE -
4-' ft. I St-1 ft. a in. V'V
Company Name
16.INNER CASING OR TUBING eothernial closed-hio".'
2.Well Construction Permit#: 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 E3Municipal/Public ft. 3a ft. in.
bl,� cv+C-b��
_,,
__i Geothermal(Heating/Cooling Supply) glResidential
..esidential Water Supply(single) ft. ft. in.
Industrial/Commercial Water Supply(shared) l8i'GROUT u.
_ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. h C ft. �; baco _ IOill�
Monitoring Recovery ft. O1 ft.
Injection Well:
ft. ft.
_ Aquifer Recharge ®Groundwater Remediation 19:SAND/GRAVE
PACK(tf'a 4icdtile _
Aquifer Storage and Recovery FnISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
__.Aquifer Test 0 Stonnwater Drainage ft. "11D fL
Experimental Technology EISubsidence Control
__, Geothermal(Closed Loop) r.1ITracer 20.DRILLING LOG"(atfacGudditiorial shectidf'ndi6iaLL
� 1
_,Geothermal(Heating/Cooling Rectum FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,eta)
) I Other(explain under#21 Remarks) ft. � ft. �
4.Date Well(s)Completed:5-5 �� Well ID# ft. ft. soti)f
5a.Well Location: ft. 18 ft. ��
1 I � nt
Facility/OwnerNale ' ` r�/�� Facility ID#(if applicable) ,,�( �� ft. 1 ft. ( l�i�
%� W eW �J1.41.. son �V u � aunt 1 i 11 u I t ft. ft.
Physical Address,`C,�ity�and Zip
ft. ft.
l l.ov`QI`(�1 21.REMARKS :(:p
County Parcel Identification No.(PIN) 3� - ` +•a✓ ts
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:`° a._°` L
(ifwell field,one lat/long is sufficient) 22.Certification: MAY 18
3�° i t 3`48 N ��� `�lQ t ISIP �t 2022
6.Is(are)the well(s)01
Permanent or []]Temporary Signature of C ified Well Co ctor i y�J J,� j aJgJ+1�
thaY tl" i YiNSS�ili r'
,,,,����[[[[ By signing this form,1 hereby certify t the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consrnrction Standards and that a
If this is a repair,fill out known well construction information nd 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: LAD (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@1200'and 2@100') construction to the following:
10.Static water level below top of casing: l (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: `r (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: t r I
�n�UA K 1�T0.Y1�Z,�\ & above, also submit one copy of this form within 30 days of completion of well(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) l� Method of test: U � 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: vI I Amount: "C completion of well construction ito the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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