GW1-2022-10609_Well Construction - GW1_20221122

IF—P Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Wo Contractor Information:
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 'ft.
NC Well Contractor Certification Number :j15;OUTER CASING for multi-cased,wells OR LINER(if a licable)
FROM TO DIAMETER THICKNESS MATERIAL
V
ft. I p ft. q in.
Company Name 16.INNER CASING.OR TUBING(eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft• tY. 1O'
3.Well Use(check well use): ft, ft. M.
Water Supply Well: FR M TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural DMunicipal/Public ft. ft. in;
- Geothermal(Heating/Cooling Supply) 1-' esidential Water Supply(single) ft. ft. in.'
:)Industrial/Commercial I-Residential Water Supply(shared) ;`18.GROUT
.71 Irrigation FROM TO MATERIAL EMPLACEMENT THOD&AMOUNT'
Non-Water Supply Well: ft. ft. ,
Monitoring 0<1 covery
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
_
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
_ FROM To DESCRIPTION(color,hardness,soitt ock type,grain size,etc.)
I Geothermal(Heating/Cooling Return) L-_Other(explain under#21 Remarks)
4.Date Well(s)Completed: Well ID#
So.Well Location:
17,61 ft. ft. 2 2Q2°
Facili /O her Name Facility ID#(if applicable) ^� ft. ft.
`� / ft. ft.
Poly
Physical Address,Ci ,and Zip ft. ft.
/� /s � 21.REMARKS
�Amon, Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s) ermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: gles or FINo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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 farm.
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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: //_,�,.�� SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: 1 60 (ft-) 24a•For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(exlrmple-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: c/o (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: Cs'1'`�� (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: V_r p'�"rc above, also submit one copy of this form within 30 days of completion of well
�J'I construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY/WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) V Method of test v 24c.For Water Supply&Iniection Wells: In addition to sending the form to
I1 j, the address(es) above, also submit lone copy of this forth within 30 days of
13b.Disinfection type: `/4-H Amount: 5.Ai,,;aiev5 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
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