GW1-2023-01411_Well Construction - GW1_20230208

WELL CONSTRUCTION RECORD(GW-1) For Internal Use only:
1.Well Contractor Information:
�/X���t1 ( /� �v 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor
ft. g
�t v
ft. ft.
NC Well Con ctor Certification NTber 15.OUTER CASING(for multi-cased wells OR LINER if a 1icaWe
DIAMETER THICKNESS MATERI L
\4 , 'Pie .ctim ,+..r_. ft. ft.
Company Name ,^ 16. NNER CASING OR TUBING eothermaI closed-loop)
2.Well Construction Permit#• 32�Q/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(ie.UIC,County,State.Variance,etc.) ft. ft. in
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well:
pp)' FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural icipaMblic
[3 ft. et. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: et' et. '�j d C I
Monitoring Recovery
Injection Well:
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK it applicable)
Aquifer Storage and Recovery MSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft. —
Experimental Technology E]Subsidence Control ft. et.
Geothermal(Closed Loop) ElTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,-
ardness,wil/ro k type, min sin,etc.)
Geothermal(Heating/CoolingReturn) Other ex lain under#21 Remarks ft. fc. _._.
4.Date Well(s)Completed: �1 a••l Well ID# ft.
ft. ft. F
5a.We tll Location: —
Facility/Owner Name Facility ID#(if applicable) Ft. ft.
ft. ft,
Physical Address,City,and Zip
d( 21.REMARKS
County Parcel Identification No.(PIN) t KC
5b.Latitude and longitude in degrees/minates/seconds or decimal degrees:
(�we011 field,of a lat/I��i j sufficient) ��a �� J ��I 1 22.Certification: � 1
1V 4i 5 N W
6.Is(are)the well(s) ermanent or mporary Sib&ure of Certified Well Contractor Date
By signing this form,I hereby certify t well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: es or QNo with 15A NCAC 02C.0100 or 15A NCA 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 p SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: L O (B-) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di,(ferent(example-3Q200'0'and 2@100) construction to the following:
10.Static water level below top of casing: v y� (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: 1 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: v M P 24c.For Water Supply&Injection Wells: In addition to sending the form to
G the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: ` O Una, 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