GW1-2023-01479_Well Construction - GW1_20230209

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: f
�� n ��'� T f �, 14.WATER ZONES
-�- n 1111 FROM TO DESCRIPTION
Well Contractor Na
m11e ft. 3 ft. F`•n
sk 1
ft.
NC`Well
Contractor Certification Number / IS.OUTER CASING for multi-cased wells OR LINER if a livable)
t �ar !iIV� �w / I FROM T DIAMETER THICKNESS MATERIAL
` ,(� ft. ft. in. V
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Constriction Permit# FROM TOI DIAMETER Tf 11 CKNESS MATERIAL
List all applicable well construction permits(i e.UIC,County,State,Variance,etc.) ft. ft. in.
ft.3.Well Use(check well use): ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TIUCKNF.SS 1.1A'I'IiR1A1.
Agricultural [3M IcipaUPublic p ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft,
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL 1PLACEMENT ETHOD& MO T
Non-Water Supply Well: ft. n. Vol Ck
Monitoring DRecovery ft. ft.
Injection Well:
Aquifer Recharge QGroundwater Remediation
r20.
AND/GRAVEL PACK if a livable
Aquifer Storage and Recovery Salinity Barrier M TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft• ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer RILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,wiVrock t in size,etc.)
Geothermal(Heating/Cooling1�Re�tum Other(explain under#21 Remarks ft. ft.
4.Date Well(s)Completed:1 tT Well ID# ft. -
ft. ft. -
Sa.Well K Location: —
�.� ku'J . ft. ft. — (,
Facility/ ter Name Pacili [D#(if plicable) ft. ft.
� ft.
Physical Address,City,and Zip � 21.REMARKS A
qi!ca pL ^ \'(/ f ft.
County Parcel Identification No.(PIN)
Itn L can c
5b.Latitude and longitude in degrees/minates/seconds or decimal degrees: y
(if well Meld,one lat/long is sufficient) 22.Certification: Atj W'p
N 7� 01 ' LQ W
6.Is(are)the weil(s) Permanent or [:)T rary Signature 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 []No with 15A NCAC 02C.0100 or 15A NC 22C.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: (B•) 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: 1_ (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use ' 1617 Mail Service Center,Raleigh,NC 27699-1617
I
11.Borehole diameter. (in.) 24b.For Infection 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: r� - 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
1
13a.Yield(gpm) ` Method of test: / M N 24c.For Water Sipnly& Infection 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: Amount: L)J n L�t completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016