GW1-2022-10612_Well Construction - GW1_20221122

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
lsan (jPn 4 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION /�,.,
t y & ' C ft. cily
ft. � + . l
7 ft. I ft.
NC Well CT't
tractor Certificatio Number t
q � nl I5.OUTER CASING(formulti-cased weld)OR LINER if a licable)
W G 7, c �'�!'7iCt I �S �n L M TO DIAMETER THICKNESS MATERIAL
ft. ft. rn. S(J •��!
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) (Y• ft• in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
—)Agricultural DM30' al/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) _ estdential Water Supply(single) in.
_ Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
'!Irrigation FROM TO MATERIAL LACEMENKr METHOD&AMOUNT
Non-Water Supply Well: ft. ft. QdT.
Monitoring QRecovery 1
Injection Well:
ft. ft.
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test E]Stormwater Drainage
:)Experimental Technology OSubsidence Control
:)Geothermal 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, o soil/ k type,grain size etc.)
���
4.Date Well(s)Completed:J — Well ID# V
So.Well Loc lion:
DC U,t1 f ,d� �o� ft. ft. y `'�.� �0 0.-..a `i2' ate• +°
Facility/Owner Name Facility ID#(if applicable) ft. ft. 022
36�5� s1-�►0rfi�,11�t 1\�W��r� �V• ft. ft. - =--
ft. ft. iu lniY�`s1C❑ t i.r��m•
Physical Address,City,and Zip
tP/�S Q 21.REMARKS
County a Parcel Identification No.(P1N) /\.` a• ew
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: k&-4/Ix° It
(if well field,one lat/long is sufficient) 22.Certification:
" N 7�Za �.' `�7,5�3a �, W
6.Is(are)the well(s)dermatient or Zesoro
prary Si of Certified Well Contractor Date _
By signing this form,I hereby certify t a71heell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: It; QNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 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 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: 1 SUBMITTAL INSTRUCTIONS
Q(�
9.Total well depth below land surface: Y 11 V A) 24a,For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a200'and 2@100') construction to the following:
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: ra 24b.For Iniection Wells: In addition to sending the form to the address in 24a
r above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1 a(- 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) Method of test: 24c.For Water SuuDly&Iniection Wells: In addition to sending the form to
}� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: + Amount: 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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