GW1-2022-08510_Well Construction - GW1_20220518

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
�c1`T I - \ V V' L k 1 Y 14.WATER ZONES
1 `
Well Contractor Name
� ( FROM TO DESCRIPTION
31A
ft. ft- A 1✓ C^ y�
ft. ft. l
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a 6cable)
1\; ` ^\�1\ ��11` ^„ FROM TO DIAMETER THICKNESS MATERIAL
\f y 1 ` .•=r-1 ft. 3 q ft. in. L
Company Name
(� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: �� -1G�� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Cou til)•,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 t. ft. in• 11�'.f
❑Geothermal(Heating/Cooling Supply) CResidential Water Supply(single) ft. ft, in.
❑Industrial/Commercial &esidential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q
❑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 0 ft. '+� ft.
❑Experimental Technology El Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
D ft. f ft. .- Sol'/
4.Date Well(s)Completed:C�13 Well ID# ft. ft. r t S G u
5a.Well Location: ft. 2 ft. h 044
Sm '4 2 V. ft. l t t,G li, G ct
Facility/Owner Name Facility ID#(if applicable) 3 ft. 2
J
Physical Address,City,and Zip
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlong is sufficient) 22.Certification �f a7I Tl+
3 i s -`Ll`0 �N - r�19 t 4 7 9 (Le W
6.Is(are)the well(s): ermanent or ❑Temporary Signature of Certi dwell Con[mcto Date
By signing this form,I hereby certify that the well(s)was(svere)constructed in accordance with
7.IS this a repair to an existing well: ❑Yes or No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known w on hell construction formation a nd-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 constriction 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: 2 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (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)
0.Static water level below top of casing: (� (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
1
1 water level is above casing,use op 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: 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: m j
13b.Disinfection type: 1-1 l Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of water Resources Revised 6-6-2018
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