GW1-2022-09000_Well Construction - GW1_20220923

=.' Print Form
WELL CONSTRUCTION RECORD(GW-1) For telnal Use Only:
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1.Well Contractor information:
` 13 a) PRO ATER ZONES TO DESCRIPTI
O.
Well Contractor Name
ft. ft.
NC Well Contractor Certification Number S E P 2 V
2022 15. TER CASING for multi-cased viells OR LiNER Qfa2 livable
�.. FROM TO DIAMETER THICKNESS MATERIAL
Y1 G rc. UL kt. cldn. C.
Company Name
16:FINER CASING OR TUBING eotbermal closed-loo
2.Well Construction Permit#: 6 FRO TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pernnhs 6.e.UIC,Counh•,State,Variance•etc.) ft. fL in•
ft.3.Well Use(check well use): ft. in.
17.S REEN
Water Supply Well: r.�., - -, .FRO !- - TO- -DIAMETER.. SLOTSILF-- THICKNESS MATERIAL
Agricultural Municipal/Public
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared) 19.C ROUT
Irrigation FRO 1 TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
t ft.
Non-Water Supply Well: R' Q
Monitoring Recovery
Injection Well: ft. tt.
Aquifer Recharge QGroundwater Remediation 19.S ND/GRAVEL PACK if:a livable .
Aquifer Storage and Recovery Salinity Barrier FRO 1 TO MATFRIAI. EMPLACEMFNT METHOD
Aquifer Test [3Stomiwater Drainage ft. ft.
_ Experimental Technology OSubsidencc Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20: RiLLING LOG attach additional Atets if becessa
FRO 1 TO DESCRIPTION(color,hardness,sollfroek c, in she,etc.
Geothermal(Heating/Cooling Returrn)�����.••��Other(explain under#21 Remarks) tt t ft.
4.Date Well(s)Completed:;�-Well 1D# fi• t ft.
ft. 66 ft. �;
Sa.Well Locatio
Facility/Owner Name Facility ID#(ifapplicablc) ft' fL
r ft' ft.
ft. ft.
Phys•al ddress,City,and Zip
21.:1 ENIARKS.
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:�
N W ONVMU�L dJ� l %AA —O
6.Is(are)the well(s) Permanent or Temporary 021g
ore ofCertified Well Contractor Date
ning thisform,I hereby certify that the w•ell(s)was(were)constructed in accordance
7.is this a repair to an existing well: ]Yes orXd7ainthenature9fthe
o A NCAC 02C.0100 or i5A NC4C 02C.0200 Well Construction S'tandardc and that a
Ifthis is a repair,fill an known well construction h jornationl this record has been provided to the well owner.
repair tender#21 remarks section or on the back of this form. 23.S to diagram or additional well details:
R.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You nay use the back of this page to provide additional well site details or well
construction,pnly 1 GW-1 is needed. Indicate TOTAL NUMBER of wells cons ction details. You may also anach additional pages if necessary.
drilled: SUB 4ITTAL INSTRUCTIONS
9.Total well depth below land surface: l JIJI 11 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple tvel&list all depths ifdifferent(example--3(3200'and 204100) consl ruction to the following:
10.Static water level below top of casing: ZL` (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use'+' 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: LD (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
L„ abov ,also submit one copy of this!form within 30 days of completion of well
- ---- - - -- --- -- —
lY:WeIi construction-method:�) 1 t.0 L � cons ruction to the following: �.
(i.e.auger,rotary,cable,direct push,etc.)
11 ivision of Water Resources,!Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test• WIK 24c.For'Water Supply&Iniection Well`s:•In addition to sending the forni to
theaddress(es) above, also submit one copy_of this form within 30 days of
136.Disinfection' Amount:Amount: completion of well construction to the county health department of the county
whet a constructed.
Form GW-I North Carolina Department of Environmental Qu lily-Division of Water Resources Revised 2-22-2016