GW1-2022-09707_Well Construction - GW1_20220518

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: %([F i e I d.I D #])
Ua Y\A ys `l`,I fb 11k- J r 14.WATER ZONES
Well Contractor Nama FROM TO DESCRIPTION
ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a able)
��,\1,:}-•.�,��,� .p 1 '� ,,.-i 11; FROM TO DIAMETER THICKN`ES�S MATERIAL
u 4-A ft. 2� ft.
A in. s"h`tiL) Pvc,
Company Name pp 16.INNER CA✓SING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: L �1 a�'� 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 2 ft- -3s ft. in, 0,
[] A sds4ln
Geothermal(Heating/Cooling Supply) residential Water Supply(single) 7 ft. ft. in•
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Oft. a� ft.
❑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 p ft. 3% ft- j
❑Experimental Technology ❑Subsidence Control ft. 7 ft. u
[]Geothermal(Closed Loop) []Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock t e,grain size,etc.)
s.& t- -
4.Date Well(s)Completed: Well ID# ` u
5a.Well Location: 1 ft. rk G Ck`
(15 ft. 141
,ft. �s rJt n
Facility/Owner Name Facility ID#(if applicable) �'�It. 3 _ ft. &, C L 1 fA
15 �a�r• _ t�� ( 2y�S�(1 N�, '1SL� 3 3 ft. 3 22.
Si�1 n
Physical Address,City,and Zip ft. ft. ➢�`� "�, �
21.REMARKS - ---"--"
County Parcel Identification No.(PIN) MAY 18 9
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,,,
fiil
,�
(if well field,one IaUlong is sufficient) (� 22.Certification: �P '" -) , I T
35 ,30 LC-f N !1 1� 9 -1"l W
r l w
6.Is(are)the well(s): 6Pe'Ymanent or ❑Temporary Signature of Certo6d Well Contractit Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or l6o 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 curd 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: 20 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3R (ft.) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2 @I00')
�J (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
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: LO (in.) 24b.For Injection Wells: Copy to DWR,Underground hnection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: K 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) Method of test: DOrnoirkA
Permit Program, 1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
I ,