GW1-2022-10779_Well Construction - GW1_20221208

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Iufor tion:
ATER2AHES
FROM TO DESCREMON
Well Contractor Nama JJ ft. ft.
fCD A ft. ft.
NC Wall CoZtor Certification Numberr ///��� 13rOTITER.CASING.for•inul cased wells 01t LINER'if a licable
FROM TO DIAMETER THICtQJFSS MATEIUAL
ft. �- � , z5�• S D R�1 P V G
Company Name I6,'INNER CASING t)R'.T LNG• eottiecmdl'alosed-too
TO DIAMETER THICIOVFSS MATERIAL
2.Well Construction Permit#: In..
t�r FROM "
List all applicable well construction permits 0.e.UIC,County,State,Variance,etc.)
fL tL
ft. ft. in,
3.Well Use(check well use):
IZ.'SOREEN
Fgn
upply Well: FROM TO DIAMETER SLOT SIZE THIC[OVESS MATERIAL
ltural E]Municipal/Pitblic ft. fL �O
rmal(Heating/Cooling Supply) residential Water Supply(single) ft, ft. in
ial/Commercial [3Residential Water Supply(shared) 1s.•GR'QUT
FROM TO MA EMPLACEMENT OD&AMOUNT
ion
ter Supply Well: O ft �� ft. = �K �h p u YE
ring Recovery ft. ft
n Well: ft. ft.
r Recharge Groundwater Remediation 19,SAND/GRAVEL EAGK..if•a llcr Storage and Recovery - Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 'x, ,.. [3StormwaterDrainage ft ft
A tt, tL
Experimental Technology fit.y' Subsidence Control
Geothermal(Closed Loop) DTracer 20.'DRiLLINQ LOG.attach 01116 alsheetW aecessa
FROM TO DESCRIPTION color hardness soWrock size eta
Geothermal(Heating(Cooling Return) 7Other(explain under#21 Remarks) (2 � t g
4.Date Well(s)Completed: ) 1 30-- Well ID#
. ft.
Sa.Well
Location: R
YI�U n� kJ � ft. ft. "<
Y n 0 5 ft.
Facility ifa applicable)
Facility/Owne/r�Name tY ID#( PP )
rif l
r—A-me Y r ft �^
Physcal Address, tyZ r t1
�� � o►��.� I _ip 21.RE ARILS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/secon4s or decimal degrees:
(if well field,one lat/long is sufficient) 22•Certification:
Date
6.Is(are)the well .$) Permanent or,Temporary Signature ofCertified Well Contractor
- By signing!his form./hereby sett fy that the wells)was(wcre)constructed in accordance
7,is this a repair to an existing well: ®Yes or No with ISA 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 notate ojlhe copy of this record has been provided to the well owner.
rdpair 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'Geothcrmal 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: SUBMnTAL INSTRUCTIQNS
9.Total well depth below land surface:y (IL) 249. For All Wells: Submit;thus form within 30 days of completion of well
For multiple wells list all depths If direrent(example-3@200"and 2Qa 100) construction to the following:
10.Static water level below top of casing: 106 (H•) Division of Water Resources,Information Processing Unit,
if water level is above caring,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter (10 24b.For Injection Wells: Iu addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ��y 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 Su v&Infection Wells: in addition to sending the form to
t the address(es) above, also subnut one copy of this form within 30 days of
13b.Disinfection type: he Amount: CIL completion of well construction!to the county health department of the county
where constructed. '
Revised 2-22-2016
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources