GW1--03329_Well Construction - GW1_20230516

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
�d+ 14.WATER ZONES,
Well Contractor-Name
FROM TO DESCRIPTION
a-
3 ft. ft.
NC Well Contractor Certification Number L OUTER CASIlHGWoi tndlU=cases wails ORLINL�R La arable "
� / FROM TO DIAMETER THICKNESS MATERIAr.
Company Name
��/ I&INNER CASING OR TUBING(eotirerm�al closed-loop)2.Well Construction Permit#: FROM To I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i e.UiC,County.State,Variance,etc.) ft. fL in.
3.Well Use(check well use): fL fL
Water Supply We➢: 17.SCREEN
FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
Agricultural E-.-jM cipal/Public G ft- ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. M
Industrial/Commercial QlResidential Water Supply(shared)
18.GROUT,
Irri ation - FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. IL h f
_Monitoring ' Recovery
Injection Well: ft, ft.
Aquifer'Recharge oGroundwaterRemediation
19.SANDlGRAVEI.PACK(if a licnble
Aquifer Storage and Recovery OSaIinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft, ft.
ExperimentalTechnology Subsidence Control ft.
Geothermal(Closed Loop) OTracer 20.DRILLING.LOG attach additional sheets if n y�1
Geothermal(Heating(Coolin Return) _ Other(explain under#21 Remarks) FROM To DESCRIPTION(color.hardness,soivmcr a etc.
ft. ft.
4.Date Well(s)Completed: 3�6 �2�`WellID ft' ft'
5a.Well Location: // f t.
�1..l6d ft.
S®
Faeility/OwnerName Facility ID#(if applicable) ft. ft. r
ft. fL 7
6 2923
Physical Address,City,and Zip r Z? fL ft.
"Is I D l 21.REt6lARKS- .C.-`Qi �,,.r,
u
county � Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minafes/seconds or decimal degrees:
(ifwell field,one ladlong is sufficient) 22.Certification:
36. 1y&o8?3 N —�9. l�20(-/A8 W
6.Is(are)the wells) Permanent or Temporary Si tare of Certified W ntractor Date
Bp signing this form,I hereby certi that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: MYes or QK6 with I SA 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: A) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3©2200'and 2®100) construction to the following'
10.Static water level below bap of casing: (fL) 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:IG�y� (in) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
nn above,also submit one copy of this form within 30 days of completion of well
12.Wed construction method: /� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground bdection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: .o H For Water Supply&Iniection Wells: In addition to sending the form to
tlre.address(es) above, also submit one copy of this form within 30 days of
131b.Disinfection type: Amount Z1 a.w nG6 s 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