GW1-2023-02341_Well Construction - GW1_20230331

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
R" !2—ariu(' 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
aC l!/z ft. 3�I
ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if ap cable)
FROM TO DIAMETER THICKNESS MATERIAL
l:kGCS W �(ff� L f1 C. ft. f ft. / J t/ in. 154
r/11 JP
UC
Company Name 16.INNER CASING OR TUBING( eothermat closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I 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 [3MunicipaUPublic 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
IndustriaUCommercial Residential Water Supply(shared)
18.GROUT
I Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft.
Monitoring ;, Recovery
Injection Well:
ft. ft.
DAquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK if applicable)
f Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
f Aquifer Test rIStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) [ !Tracer 20.DRILLING LOG attach additional sheets if necessary)
!Geothermal(Heating/Cooling Return) - Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnesw,somrock type,grain size,etc.)
ft. ft.
4.Date Well(s)Completed: ' � Well ED#
5a.Well rLocation:
•50
Facility/Owner
rName �pFacility IDt#�(if applicable) ft. ft. MAR 1
�19t�1 01A, .l✓+Iy� uf//?0
Physical Address,City,and Zip ft. ft. 1
CCU
/'„rr� 21.REMARKS / -
County /� Parcel Identification No.(PIN) �� C` _ r�/
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N --n,G6o,"?` �/r'� W ,e,1< 1Cj
6.Is(are)the well(s) rmanent or OTemporary Signature of Certified Well 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: s or ONo 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-I 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: "1 (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@100) construction to the following:
10.Static water level below top of casing: I'll (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+t 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: lq (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
j_Y,_,d, above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: �� 4�� 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
r
13a.Yield(gpm) Method of test: A 24c.For Water Supply&Iniection Wells: In addition to sending the form to
rrI the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: t Amount: ,06rd 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