GW1-2022-10310_Well Construction - GW1_20221114

WELL CONSTRUCTION RECO (GW-I) For Internal Use Only:
1.Well ContraoInma on: �� 14.WATER ZONES
Well Contractor ame r' FROM TO DESCRIPTION
ft. ft
ft ft
NC Well Contractor Certification Numbeyr
�`ri 15.OUTER CASING for multi-cased wells OR LINER rf applicable)
mom TO DIAMETER THICKNESS MATERW
Company Name ft ft in
�] I 16.INNER CASING OR TUBING eothermal closed-loIo
2.Well Construction Permit#:- ! jS I FROM I TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permlts(i.a.EUC County.State,Variance,eta) & fL S jy in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 7.SCREEN
❑A Cultural FROM TO DIAMETER ISLOTSIZE THICKNESS MATERIAL
l;n •❑Mtmicipal/Public ft ft ... iu.
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single)
ft I ft in.'
❑lndustrial/Commercial OResidential'Water Supply(shared)
• 18.GROUT �
❑h'ri tion OWells>100,000 GPD FROM I TO I EMPLACEMENTMEiHOD&AMOUNT
Non-Water Supply Well: ft ?> ft u r
roMonitoring ❑Recovery ftfction Well:uiferltechar a ftft
g ❑GroundwaterRemediationuifer Storage and Recovery ❑Sal' ' Barrier .SAND/GRAVEL PACK tf a liableFROM TO MATERIAL EMPLACEMENTMETHOD
uiferTest OStormwaterDrainage ft ft
erimental Technology ❑Subsidence Control fc ft
O'Geothernlal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DFSCRIMION color,hardness soillrock in a' ete
ft ft
4.Date Well(s)Completed: I—?J-Z?i Well m# ft tt
5a.Well Location: ft ft
ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft 'j
ft-her- : 202
Physical Address,City,and zip J G � Yj^ ft I�Orm"O,'1 Pf
—` / r 21.REMARKS d
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 2 r 22 Certification:
/� ' �7/�N� 3 ' `7V- ' W
6.Is(are)the well(s): ❑Permanent or OTemporary otS OO Stgoature o Cerhfied'•Well Contractor 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 Ofto 15ANCAC 01C:0100 or'ISANCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out]Drown well construction hiformation and explain the nature of the of this record has been provided to the well owner
repair under#21 remarks section or on the back ojthis form.
23.Site diagram or additional well details:
S.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 Ovel'in Remarks Box).You may also attach additional pages if necessary.
drilled:
D If 24 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (f�)
For multiple wells list all depths ifdperent(example-3@200'and 20a 100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ijwarer level is above casing use +'f Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 1/0 ,(in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well-construction method:_ Ar—
(i.e.auger,rotary,cable,direct push eta.) 24c.For Water SUDnly and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d For Water Wells Droducint;'over 100 000 GPD Co to D
13a.Yield(gpm) Method of test: �(� Permit Program,1611 MSC,Raleigh,NC 27699-1611 Copy 'CCPCUA
i5
13b.Disinfection type: Amount
i
Form GW-1 D North Carolina Department of Environmental Quality-Division of Water Resources
• Revised 6-6-2018