GW1-2022-08418_Well Construction - GW1_20220517

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Inifor�mation:
Lanu 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
Rci ft. ft. n
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a livable)
FROM TO DIAMETER THICKNESS MATERIAL
�"1 ft. gC?' ft. in.
Company Name � 16.INNER CASING OR TUBING(geothermal closed-loop)
^✓2.Well Construction Permit#: 5 L--Q' 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):
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 9 ft. c q ft. 2 in. q
4
❑Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft. ft. in.
❑hidustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. Q ft. BC O v�, _ OU
❑Monitoring ❑Recovery
Injection Well:
El 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 'a Ift
ft. 1 t
❑Experimental Technology El Subsidence Control ft. W
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Coolingq Return) ❑Other(explain under#21 Remarks) � O
ft. 1`
4.Date Well(s)Completed: 1 ` Well ID# a ft. ft. 1 cA
Sa.Well Location: (?� ft. � ft. G L_k
S 0 e_S4 LlJlrn h be�� ft. 31
fL C®P'��Plivk5 eC tC
Facility/Owner Name I Facility ID#(if applicable) 31 ft. 7 ft. ©ry p1 ng e tJ i 1 r.-G ct
1CVlA t�o S�- '1 A 0 tno_ R7A La i �
l t met. ft. M S-o't It t
� �► �nfL ft. _
Physical Address,City,and Zip JJJ .IL. o ` I'KI'
21.REMARKS
1
County Parcel Identification No.(PIN) V 4 rt C&n•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3�{ Ib� N _,� 1 -40- W �,
--y6.Is(are)the well(s)• Kermanent or ❑Temporary Signature of Certifi ell Contractor Date
f�t;y
By signing this form,I hereby certify that the well(s)was hl i nsgitcteil,&;;chdra e with
7.Is this a repair to an existing well: ❑Yes or 116 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and teat 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 tlee well owner. MAY
1 7 2022
repair under#21 remarks section or on the back of this form, ntl!1 d L
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 additio al:well:cow-sui��tion info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may alsq�#Mtacb�diIWal pages0ngeessaty
drilled: {I.hiriVi4Ai 1F :J.,k��"e
(tea 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 1 (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')
24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.)
10.Static water level below top of casing: Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: U (in.) 24b.For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: vyuoK A24c.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
c ,\13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
V
13b.Disinfection type: 1 Amount: L4t
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018