GW1--03436_Well Construction - GW1_20230516

IF Print Form
WELL CONSTRUCTION RECORD GW-1 For Internal Use Only:
1.Well Contractor Information:
J��d h 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
Izaft. ft. irk 6-
.31� �� ft ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
LL / r I FROM TO DIAMETER TffiCKNESS MATERIAL
U GC f)4r`dll Well p r lwy !/� /S fL fL a RR I vc
Company Name v
I '[y) 16.INNER CASING OR TUBING(geothermal closed400
2.Well Construction Permit#: 7I FROM I 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): & it. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 0 ft. ft. in•
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft.
IndustrialICommercial D Residential Water Supply(shared)
18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD AMOUNT
Non-Water Supply Well: fL ft
Monitoring Recovery ft. It.
Injection Well: ft ft {
Aquifer Recharge DGroundwater Remediation
19.SANDIGRAVEL PACK if applicable)
`
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERrM. EMlttlei iMET.ILQD-F
Aquifer Test [3Stormwater Drainage ft. ft. t= C
Experimental Technology OSubsidence Control ft. ft GTrr:w.'c 1 ?r ,_•�
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary) -ti
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness oillrock type,grain size,etc
ft ft.
4.Date Well(s)Completed: /S ad, Well ID# ft. ft ! e� ✓!7/
5a.Well Location: J ft Q fL t I /, KO t�
Orei.l p/ 1��� ft ft. / / GIWJ
Facility/Owner Name Facility ID#(if applicable) ft l q0 ft �`jG y
)Obu�It, a-=�6/��d/ fl/c_ ft a ft -- ------ -----
Physical Addles ity,and Zip ft. ft.
unigh lam b�P lay �30A 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification: //-'�
N W
6.Is(are)the well(s)! ermanent or Temporary S of rtifi ell Contd
Date
signing this form,I hereby cat the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or To ith ISA NCAC 02C.0100 or IC 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
t
9.Total well depth below land surface: (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(a 200'and 2(a OOD construction to the following:
10.Static water level below top of casing: lS (ft) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" r 1617 Mail Service Center,Raleigh,NC 27699-1617
Al 11.Borehole diameter: - (in.) 24b.For Injection 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: I 6 HIV 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) AI Method of test: b6z 24c.For Water Supply&Iniection 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 GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016