_Well Construction - GW1_20230315 (10)

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
FROM TO DESCRIPTION
Wel Contractor Name( 114 ft. /o Ci l
ft. 1 �j
L/ J" C 7 «. I «.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a bk
Th v" FROM TO DIAMETER THICKNESS M ERIAL
' ` U ft. 14 ft. L in. 5�� G'
Company Name 1611
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#f: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. «. in.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public 0 ft. «. in.
Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft. ft. in.
Industrial/Commercial 13Residential Water Supply(shared) I&GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. Gy
Monitoring overy
Injection Well:
n. n.
Aquifer Recharge [3Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E]Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnew,wiltruck type,OsIn size,etc.
«. n.
4.Date Well(s)Completed: c'` t Well ID#
5a.Well Location:
Facility/Owner Name Facility ID#(if applicable)
ft. «.
13 C^r I`V\ f e')A ^i' J �� ft. ft.
Physical Address,City,and Zip ft. «.
0 er,-; 21.REMARKS
Co6nty Parcel Identification No.(PIN) 1 r ��.. f d r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) ( / / 22.C ication:
6.Is(are)the well(s)QW.- nent 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: I.I'_ or 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 l GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: too —(ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: h (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: �� (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
i�c7� i above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: r —� 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 Supply& Iniection Wells: In addition to sending the form to
Ij !� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: r1 Amount: JCtti+�+ completion of well construction to the county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016