GW1-2023-01629_Well Construction - GW1_20230214

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Informattiion:
14.-io) FROM WATER ZONES TO DESCRIPTION
Well Contractor Name
rr�� to
'1 oG 1q 'A ft. tt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells 01Im if a licable
' FROM TO DIAMETER THICKNESS MATERIAL
t
]r� b��e ft. �J ft. in.
Company Name �V
0 ���_ � 16.INNER CAS G OR TUBING(geothermal dosed-loop)::
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(r.e.UI ,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SC
Water Supply Well: FROM REE TO DIAMETER, SLOT SIZE THICKNESS MATIERIAL
❑Agricultural ❑Municipal/Public ft. tt. in.
❑Geothermal(Heating/Cooling Supply) [Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑kfi ation ❑Wells>100,000 GPD FROM I TO MATE41AL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 0 ft.
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK"if a licabte
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage It-
t ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets If necessar
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)_J
FROM TO DESCRIPTION color,hardness,soll/rock type,grain size,etc.
D ft. ft. L
4.Date Well(s)Completed: Z� Well ID# ft.
5a.Well Location: ft. ft. O L
Pe1qqr S ft. ft.
FacilicygAAIName y CFacility ID#(if applicable))
4 7-0 G �''7�4� f I r u N u! 1 V7
Physical Address,City,and Zip ft. ft.
21.1tEMARxs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cer atlOn:
N W
6.Is(are)the well(s): 4ermanent or ❑Temporary Si ure of Certified Well ntrac or Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Oyes or 4o 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#11 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths iij'differ•ent(example-3(P00'and 1Q100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
if Static water level below top of casing: �0 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
11.Borehole diameter: (in,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: r" 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: / 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
0 ",l Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 20 Method of test: IUf I v�
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018