GW1--03432_Well Construction - GW1_20230516

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1..►Well Contractor Information:
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
�I� ft. ft.
ft. a ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Dwight Hunter FROM TO DIAMETER THICKNESS MATERIAL
® ft. 3S ft 6W. in.
Company Name lc/
22-386 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
I Agricultural QMunicipal/Public ft. ft. in.
I Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
X hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: tt. 2-9 ft' 1 N� '
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
13 Aquifer Recharge Groundwater Remediation
_ 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test D Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG(attach additional sheets if necessary)
_ FROM TO DESCRIPTION(color,hardness,soil/rock F rain size,etc.
—Geothermal(Heating/Cooling Return) . Other(explain under#21 Remarks) FROM
ho ft.
4.Date Well(s)Completed:f�-�" Well ID# N ft' L & ft. t�
Sa.Well Location: q
Jennifer&Britt Thomas u ft. 24
Facility/Owner Name Facility ID#(if applicable) I $ tt. 3 00
506 Meadowsweet Ln.Waxhaw, NC 28173 ft. ft. U
Physical Address,City,and Zip tt. ft.
Union 21.REMARKS . .�` .rN s• ..
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: MAY
(if well field,one lat/long is sufficient) 22.Certification:
!n?'ci%s.,...... Uri:,
6.Is(are)the well(s)oPermanent or OTemporary 3rignatureofCertified 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: [IYes or E]No 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: ��rr 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 /�vy 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd8erent(example-3@200'and 2@100) construction to the following:t
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
11.Borehole diameter: 6 1/4 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Rotary 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) d D Method of test: Blow 24c.For Water SUDDIV&Iniection Wells: In addition to sending the form to
t the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: �13L 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
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