GW1-2022-09343_Well Construction - GW1_20221010

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
: 4 WATER ZONES
Well ComractarName FROM TO DESCRIPTION
fL ft. i A7
Aft. fr. i
NC Well Contractor Certification Number Is OVlSR'C11SRVii= Q[nIn tesea Vx°1rgiElt' s`-neable `
FROM TO DIAMETER TMCKNES4 I MATERIAL
ft. 17 ft. y ln. 1/6
Company Name
2 w I&INNER CASING d iORTUBING dose
2.Well Construction Permit : G FROM To I DUN R TMCKNESS 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: 1Z SCREEN:
FROM TO DIAMETER SLOT S= THICKNESS MATERIAL
_ Agricultural unicipaMblic 0 & ft. to.
Geothermal(Heating/Cooling Supply) .— Residential Water Supply(single) ft. ft. in.
_=Industrial/Commercial tDReside�al Water Supply(shared) I&GROUT
Irri ation - FROM TO MATERIAL EMPLACEMENT METHOD ac OUNT
Non-Water Supply Well: ft �ft .. t l
Monitoring Recovery
Injection Well:
ft. ft.
Lj
AquiferRecharge nGroundwater Remediation
19.SAND/GRAYRL PACK a"licable
l
Aquifer Storage and Recovery Salinity Barrier FROM To I MATERL1i I EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology E3SubsidenCe Control M ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets ff
Geothermal eating(Coolin Return) _'Othec(explain under#21 Remarks) FROM 1
To DESCRIPTION(color,6ardn soll/hmkiyM Vain SIM etc.
ft. ft. r
4.Date Weis)Completed: 9-/ 22`well W# ft' P,Q R' G
Ldf-
ft. [t.
5a.Well Location:
��� ft. ft.
D d ar., „da-co z_
Facility/Owner Name Facility M(ifapplicable)
ft' ft
• �i ft. M _
Physical Address,City,and Zip D ft. ft.
CS,r.twl /I I a 21.PtENLARKS`
County y "Fjfarcel Identification No.(PK
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
rfwell field,one latfiong is sufficient
3b9 _N 747 a n q '.53 i � w
6.h(are)the well(s) ermaneut or Temporary Si of"ou:
or Date
4 signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or Dro with 15A NCAC 02C.0100 or ISA NCAC 02C MOO Well Construction Standards and that a
If this is a repair,fill out known well construction information and 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 GeoprobeMPP 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 ifnecessary.
drilled p� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �liC/ (ft) 24a.For All Welts: Submit ibis form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@1001 construction to the following: 1
10.Static water level below top of casing: ?,� (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: (in) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: /GO M construction to the following:
(ie.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Undeigronnd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 16M Mai Service Center,Raleigh,NC 276"16M
13a.Yield(gpm) Method of test; &pjj Wp4 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfeetlon type: f�/ 7�� Amount: la o v*nc a completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016