GW1-2023-01477_Well Construction - GW1_20230209

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Nell Contractor Information:
14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor N 1GV Name/ /, 'C 5`
t
I "I 61 l� j�tj ft. ft.
ft. tt.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER ifs Ikable
" �( /- FROM ft TO ft DIAMETER in-
THICKNESS M ERIAL
Company Name 16.INNER CASING OR TUBING eotheraud closed-loop)
2.Well Construction Permit#: 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. It. in
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 3M pal/Public 0 ft. n. ia•
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft• g In
IndustriaVCommercial Residential Water Supply(shared) 18.GROUT
Irrigation FRDM TO MATERIAL EMPLACEMENT M OD&AMOUNT
Non-Water Supply Well:
Monitoring ecovery tt. ft.
Injection Well:
ft. ft.
Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IDStormwater Drainage
Experimental Technology 13Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets it
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,sodlr k type,grain size,etc.
ft. ft.
ft. et.
4.Date Well(s)Completed: "1" �I ,. Well IDf!
5a.Well Location:
1l hu r
Facibty/v er Name Facility ID#(if applicable) ft. ft. (,
1S9 C j3ao AWS'�or�RDTtn�bed�l��L tt. ft.
Physical Address,City,and Zip 47 S Y.Sft. ft.
.:fi J`S 9 n 07 6 21•REMARKS /
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
y (if weld field, n,lat/long is sufficient) /' 22.Certification:
o S N ) g 49 0.5 W r y4i4y c -.2 L 2.1
6.Is(are)the well(s) Perrtmnent or [3Te racy 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: es or �N0 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 I 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@2200'and 2@100') construction to the following:
10.Static water level below top of casing: C1.� (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"4" 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
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: 'I 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) lb Method of test: y M 24c.For Water Supply& Iniection Wells: In addition to sending the form to
, I the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: r,+ Amount: -7 o V t\I i IV� 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