_Well Construction - GW1_20230327 (34)

j_Print Form:
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES .
Well ContrVior Name FROM TO DESCRIPTION
ft. ft.
93/ ft. ft.
NC Well-Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable,
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERUL
p ft. qY ft. 61/4 1" sd21 pvc
Company Name vv
��)/J�97\{n .-16.INNER CASING ORTUBING. eothermaldosed-loo -
2.Well Construction Permit#: W aD—0,5— /V —03,Yi95' 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. ft. in.
:17;SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural DMunicipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft.
Industrial/Commercial D Residential Water Supply(shared) ';..18.,GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft.
a 0 ft. ZoA pY
Monitoring O Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
-99.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_ Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology E3 Subsidence Control ft. ft.
Reothermal
eothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional.sheets if necessary)
(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)Other explain under#21 Remarks) ft. © ft.
° ed (f cap
4.Date Well(s)Completed: Well ID# ft. 17J ft. G i
5a.Well Location: g ft. id�, ft. rip.
Alex f''loore, ft. I ft. :T a_
ft. ft. - re. ,.• �:..,! a,'�it,�.�:....
Facility/Owner Name ^1 j/�, �i Fac/ility1ID#(if applicable) p c� >.._.
31 D &ra `-1 / kye-/i (� ! [Ln4 ty pn ft. ft A11 2
Physical Address,City,and Zip ft. ft.
(7al 1�01rd 21:REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field one laUlong is sufficient) 22.C¢I tiff do e
N W
6.Is(are)the well(s)OPermanent or IOTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or )No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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 921 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: 5 (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: (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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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 276991636
13a.Yield'(gpm) -30 Method of test: sight 24c.For Water Supply&Iniection Wells: In addition to sending the form to
j the address(es) above, also submit,one copy of this form within 30 days of
13b.Disinfection type: '7 T14 Amount: 0-7, 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