GW1-2022-10115_Well Construction - GW1_20221110

WELL CONSTRUCTION RECO (GW-I) For Internal Use Only:
1.Well ContrraactonInfo ation:
v ' vl/ 14.WATER ZONES
Well Contractor Name FROM TO DESCRIMTON
,35 .35 3oo ft.
5� ft
tt .
NC Well Contractor Ccrhfi 'a Number
' IS.OUTER CASING for multi-cased wells OR LINER rf a 4eable
FROM I To DIAMETER THICKNESS MATERIAL
Company Name ft ft in.
3 _/T 16.INNER CASING OR TUBING eothermal doted-loon)
2.WellConstructionPermi FROM TO DIAMETE
t#: R rBICIavESS MArERrAI
List all applicable well construction permits Ae.WC,Comury,State,Variance,etc) ft ft s, in 'h f
c l rl�
3.Well Use(check well use): & ft in
Water Supply Well: 7.SCREEN
❑A cultural FROM TO DIAMrrER SLOTSI7w THICIINFSS MATERIAL gn ❑Municipal/Public fc ft in
❑Geothermal(Heating/Cooling Supply) ..Residential Water Supply(single)
6 ft ft ia'
❑lndustrial/Commercial Residential-Water Supply(shared)
is.GROUL ---T
ClIrrigation ❑Wells>100,000 GPD FROM TO MA EMPLACEMENT METHOD d&AMOUNT
Non-Water Supply Well: 10 ft ft ear a .t.�
❑Monitoring ❑Recovery ft ft
Injection Well: ak
❑Aquifer Recharge ❑Groundwaterllemediation ft IT.
19.§At!R/GRAVELPACKr1f2nnIivahIA1
❑Aquifer Storage and Recovery ❑$alinityBarriel FROM TO MATERIAL EMPIACEMFNrMEMOD
❑Aquifer Test ❑StormwaterDrainage ft ft
❑E)perimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑TraCeT 20.DRILLING LOG sattach additional sheets if necessary)
❑Geothermal eating/COoling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIMTON color,kardness soiltrack type,grain sin,etc
ft ft
4.Date Well(s)Completed: U__1-Z Z Well ID# ft ft.
5a.Well Location: ft ft.
ft fc
Facility/ weer Name Facility M#(if applicable) ft ft
Rip
C I10c1�'�Gi r t,r Rd CIS st'n Kr �'rp,,., ,•ft ft ZZ
Physical Address,City.adYd Zip & ft l *ISO P
21.REMARKS/
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Jat/long is sufficient) 22 Certifik_#4
`
-3 3 N cation:`f a� W Lail.
6.Is(are)the well(s): ❑ ermanent or ❑Temporary a jQ I �igoature glCertrfiedb✓ell Contactor Date
Byslgning thisform,Ihereby certify that the we!!(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 15go ISANCAC.02C:0I00 or'25A NC4C 02C.0200 Well Construction Standards and that a copy
If this Is a repair,fill out known well construction information and explain the nature of the aphis record har 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 Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: .5 2-6
(ft) Submit this GW-1 within 30 days of well completion per the following:
For multlple wells list al!depths/jdderent(example-3 r@200'and 2(a)100�
10.Static water level below top of easin • Ui a (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above caring;use"+ `` g• Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: )/a (in•) 24b.For Iniection Wells:Copy to DWR,Underground Injection Control(IUC)
i- A Program,1636 MSC,Raleigh,NC 27699-1636
.Well construction method:
(Le,auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over CIA,
000 GPD•Copy to DWR,CCPCUA
13a.Yield(gpm) D Method of test: w Permit Program,1611 MSC,Raleigh,NC 27699-1611
ii
13b.Disinfection type: Amount:
Form OW-1 North Carolina Department of Favironmeatal Quality-Division of Water Resources
Revised 6-6-2018