GW1-2023-01478_Well Construction - GW1_20230209

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
WT_c I _ SA1MZSaN 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
_71ft. 7
ft. ft. M
NC Well Contractor Certification Number IS.OUTER CASING for multi-cased wells OR LINER if a licable
,^11 R I&2w1A1 S +6� FROM R TO ft• DIAMETER'n TGCKNESS� MATERIAL
LfCompany Name JI ' "UJ / 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft• ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Icipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO -MATE R AL EMPLACEMR7 METHOD&AMOUNT
Non-Water Supply Well: ft. [t. et/L 4,60
Monitoring Recovery
Injection Well:
tt. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery r3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage
Experimental Technology 13Subsidcnce Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necesm
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM ft. To ft. DESCRIPTION color,hardn wit/rock type,grain sim etc.
4.Date Well(s)Completed: a_-'a-U Well ID#
5a.Well Location:
Facility/Owner Name Facility ID#(if applicable) D' B•
Physical Address,City,and Zip ft. ft. r(• - .
Pe r-S d /� 4 7 21.REMARKS . .;
County Parcel Identification No.(PIN)
l: h
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: UA1
(if well field,one lat/long is sufficient) Q , 22.Certification:
X0 0 r ILf" N 79e s/1 �� " W
6.Is(are)the well(s) Permanent or mporary tgnature of i Well Contractor Date
By signing this orm,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or [3No with 1 SA NCAC 02C.0100 or 1 SA 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 ttse 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: l O� (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@I00') 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: L (in.) 24b.For Iniectlon Wells: In addition to sending the form to the address in 24a
v above, also submit one copy of this form within 30 days of completion of well
12.Well constriction method: r d Gl i 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: P u M p 24c.For Water Supply&Iniection 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: \A4 H Amount: S U NC e,& 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