GW1-2022-00330_Well Construction - GW1_20221222

.."J"-"" ""•".�""_".""r�_'Y Yvi"��".' �"nau.a' For Internal USe VNLY: I
This form can be used for single or multiple wells
1.Well Contractor Information):
14.WATER ZONES
IFROM TO DESCRiPT10N
Well Contractor Name, ft•
i
NC Well C ntmctor certification Number 15.OUTER CASING foe multi-ensed4ells)OR LINER(if a licnble
FROMfL TOy h• DIA�E ER THICIG�ESS StA PJAL
Company Name IJ\ 16.INNER CASING OR=TUBING ecotheirmal closed-loop)
l Z.Well Construction Permit;#: �.1 - (�, FROM T DIAETER THICKNESS MATERIAL
ti ` � "
List all applicable well consaltction pennits(i.e.County.Stare,Parlance,etc.) t'r. tr. ;n.O Mft. ft in.
3.Well Ilse(checlt well use): 17.SCREEN
Witter Supply Well: • FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
i
❑Agricultural ❑Municipal/Public ft. ft. n.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fr ft. in,
❑Industrial/Commercial ❑R1!sidential Water Supply(shared) 13.GROUT
FROM TO MATERIAL Eb1P1_ACF_%IENTM HOD A41OUVT
01n'i ation ft ft. a
Non-Water Supply Well: ✓: "lid
❑Monitoring ❑Recovery
Injection Well: - ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licablc)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL ENIPLACESIHNT METHOD
rt. rt.
❑Aquifer Test ❑StormwaterDrainage ft. rt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets irnecessa )
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION(color,hardness,sollfrock tvrpc.gmin She.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under;21 Remarks) 'I- b "' 6 ,e
rt. ft. b
4.Bate Well(s)Completed: oC rt- 166 fr.
5.Well Location;
, r b 6 " G b fLLl
��l � 1.�� ft. rt
f acthty tuner Name Facility IDf€(ifa NIcable.)
rt. ft.
rt. rr.
Pgysical Address,Ci y and Zip 21.RENIARICS n 2-2022
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification• J
(i�f ivell field,one lat/lo'n(g is sufficient)
,o Glo Q 11 cyl 1 �y
6 I ! �� 9 a N ()Vt O 3� O� 1 W ✓1'1. ��'1,� �1 t l
Signal ofCertified Well Contractor Date
6.Is(are)the well(s): W manent or OTemporaly Br signing this form,I herebv certJy that the well(s)was(ivere)constructed in accordance
with 15.1 NCAC 02C.0100 or 1SA NCAC 02C.0200 Mell Construction Standards and that a
7.is this a repair to an existing well: ❑sees or No copy of this record has been provided to the well Olivier:
lfilds is a repair,Jill out known ivell construction information and arplain the nature oflhe
repair under:=21 remarks section or on the back of tlnis form. 23.Site diagram or additional well details:
t - You may use die back of this page to provide additional well site details or well
8.Number of wells constructed: _ constriction details. You may also attach additional pages if necessary.
For multiple byevion or non-water supply wens UNLYwl(h the scone construction,),on can
submil one form. 24.Submittal Instructions:
9.Total-well depth below land surface: . 7 (ft.) 24a. For All Wells: Submit this fonn iNithin 30 days of completion of well
For multiple wells list all depths ifeli fawn(arample-3@200'and 2©1001 construction to the following:
10.Static water level below top of casing: a (ft.) Division of Water Quality,Information Processing Unit,
r 1f water level is above casing,use"+" 1617 Mail Seri-ice Center,Raleigh,NC 27699-1617
t
11.Borehole diameter: (in.) 24b. For Injection Wells: in addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: \1 construction to the following: '
(i.e.auge rol , able,direct push,etc.)
Division of Water Quality,!Underground Injection Control ProQrann,
13.FOR WA TER SUPPv WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) (_ ( itilethod of test: the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1 �`f Amount completion of well construction't i the county health department of the county
where constructed. f
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013