GW1-2022-08390_Well Construction - GW1_20220517

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
�Y14s WATER ZONES .
Well Contractor Name FROM TO DESCRIPTION
ft. ft. ;
�6u 5 Gl
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a livable)
FROM TO DIAMETER THICKNESS MATERIAL
( 4 ft. ft. in, a (t•� P\a
Company Name v`�
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. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER .SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic h t. ft. a in.
�P Cat a `G
❑Geothermal(Heating/Cooling Supply) N&sidential 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: ft. 0
❑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 ft. • Lo ft. Q
❑Experimental Technology ❑Subsidence Control ft. �t ft.
❑Geothermal(Closed Loop) []Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) FROM ft, To DESCRIPTION(color,hardness,soil/rock type,gain size,etc.)
Al
ft. r
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft. Q
k uk k ue-lo-old
ft. ft.
Facility/O n�tneer Name Facility ID#(if applicable) ft. ft.
r�
1�1 fqc- t. ft. _r,:
Physical Address,City,and Zip t ft. ft. MAY 17 n,?
C/ 'c S 4 ��J f�1r1 2y t 01 21.REMARKS
County ��j� Parcel Ildcnnttiific`a lio(ntNlo.l(`PJIN`)J _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ►'',:?'""` it it.`'� ` "'� '
(if well field,one lat/long is sufficient) 22.Certification:
3Lf i ''5b N 31 (_0 33 W
6.Is(are)the well(s): 19 rmanent or ❑Temporary Signature of Ce ed Well ContrackIr Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 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 1 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: LP (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')
10.Static water level below top of casing: IR3 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+"
Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: o 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) `V
1{� Method of test: Permit Program, 1611 MSC,Raleigh,NC 27699-1 6 1 1
{
13b.Disinfection type: l �1 Amount: I
-7
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018