GW1-2023-02011_Well Construction - GW1_20230227

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.fell Contractor Information:G.
L, i: �ti ►l r (� 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
p ft. 7 ft. O
NC Well/Contractor Certification Number '-'��[��� 15.OUTER CASING for multi-cased wells OR LINER if a [I le)
—Dig
FROM TO DIAMETER THICKNESS MATERIAL
VVVvvv ��'���JJJ V" lam/ J '�1 ft. I' ft. in. sjJQ'_.r^(C 6
Company Name
16.INNER CASING OR TUBING(geothermal 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. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural �Mun ipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
IndustriaUCommercial Residential Water Supply(shared) 18.GROAT
Iirl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o [t. —! ft.
Monitoring ecovery
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 Stormwater Drainage
rt. ft.
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,sonhock type,grain size,etc.)
tt. ft.
4.Date Well(s)Completed: Well ID#
5a.VS ell Location: ft. ft. _� _
Facility/Owner Name nn ,, Facility ID#(if applicable) ft. ft. — 7 2022
6 Q A, G�An h �! (A I
Physical Address,City,and Zip ft.
9�5 d ti 21.REMARKS
—MARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decirrml degrees:
(i well field,one lat/long is/sufficient) �i� r f 22.Certification:
' "I , ( 'f N /(J� ��'�J �,�I W0J lt-f� s4a��
11 oC
6.Is(are)the well(s) -,Went or Temporary Signature of Certified ell 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 [3No 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: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 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:
i
10.Static water level below top of casing: IQ h (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: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
/ ,r/ above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1� 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: 24c.For Water Supply& 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: completion completion of well construction to the county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016