_Well Construction - GW1_20230315 (4)

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
®� h
�D k n 14.WATER ZONES `
FROM TO DESCRIPTION
Well Contractor Name / ft. /
],{
3 O� 1 ' ft. ft.
NC Well Contractor Certification Number '15.OUTER CASING(for multi-cased wells)OR LINER(if a licable)
Ln�y �/ /j��� a FROM TO DIAMETER THICKNESS MATERIAL
w (�• ft. ft. �� in. .!•
6-3
Company Name LN�
��f 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: "� 2,I — 0 313 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) tY• B' 1D'
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. f? ft. 7�g �Q L ,9"--e-
Monitoring QRecovery
Injection Well: OD/rs
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Stormwater Drainageft. ft.
Aquifer Test �
:]Experimental Technology OSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ElOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiV` k type,grain size,etc.)
6) ft. ft. v �-
4.Date Well(s)Completed: 3' '�3 Well ID# ft. ft.
5a.Well Location: It.
ft.
�„
Facility/Owner Name Facility ID#(ifapplicable)
J 3 ,�'/�a.0
C.
Physical Address,City,and Zip ft. ft, t n ' ,
DlO.r� 019(a /&0(a$ 21.REMARKS r, t ILA
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) p 22.Certificatio�1�/J
3fV 037(02- N PZ/q770 W30 3-� �23
6.Is(are)the well(s) rmanent or Temporary Sign ure of Certified Well Qf6kraitor 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: E]Yes or L o 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (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 tQr 200'and2@100') construction to the following:
2 ✓
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: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
n above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 6Ga9 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: nn 1636 Mail Service Center,Raleigh,NC 27699-1636
J
13a.Yield(gpm) ' Method of test: LW H 44c.For Water Supply&Injection 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: r/ / �! 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