GW1-2023-01480_Well Construction - GW1_20230209

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
�CIN►1 t,�" .� 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
�J /� �_ /�J�
v.7i.L/.2'4d i"1 1 ft. t ft. r01
4i
NC Well Contractor Certification Number I5.OUTER ASING for multi-cased wells)OR LINER 1f a lkable
t ] FROM TO DIAMETER THICKNESS MATERIAL
Company Name 16.INNER CASING OR TUBING thermal closed400
2.Well Construction Permit#: qc ,r P Ll FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permlts(ix.U/C.County,State,Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft' ft. ra
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3MunicipaMblic 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) g• ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D' 62 i 61
2
Monitoring Recovery
Injection Well: ft. i c.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control ft h•
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,n,ran wlurock In size,area
ft. ft. ,� Z/
4.Date Well(s)Completed:�(i- ell ID# ft ft
5a.Well Location: ft. f ,` jCt
_
ft. ft.
A py% I p a-5-c
Facility/Owner Name Facility ON(if applicable) ft. ft.
L. -Sal�+Yt
Physical Address,City,and Zip B'
21.REMARKS
A,if��ar'i
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one
ne llat/long is sufficient) Q[- 22.Certification:
3 ,Qt t. N . �lZ, t�117-7.7 W C" A /z
6.Is(are)the well(s)Q'ermanent or Temporary
t Signa of Certified Well Can 1 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: ®Yes or 1t`3 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 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 (D•) 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 1@100) construction to the following:
10.Static water level below top of casing: Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
a
11.Borehole diameter: �' 4 (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: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test �j�t . r-C 11,1-i For Water Supply&Injection 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: [ti f.l z� 1-'_o 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