HomeMy WebLinkAboutGW1--04421_Well Construction - GW1_20240723 Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Is0 �: 14.WATER ZONES
Well✓✓✓✓Contractor Name PROM TO DESCRITLION
�„'L d1‘�C Civ a CIO ft. Imo/
ft. n
NC Well Contractor Certification Number IS.OUTER CASING(for mold-cased welk)OR LINER(if a Braille)
( �j J.,— O y►"/f•_p FROM TO DIAMETER THICKNESS MATERIAL
MATERIAL
WQ 'IL l��/ �O �— • ZJ V f. -.2 ft*
i S/^' 2 C 1L' e-e
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,&ate,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft. is
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural °MutsipaIVPublic ft ft, In.
°Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft, ft. Ia.
0Industrial/Commercial ()Residential Water Supply(shared) 1&GROUT
',Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&&AAMOUNT
Non-Water Supply Well: 0 ft' 7 ft- �,ZA -ek ekt' EN y /c.)2 boIi
°Monitoring °Recovery ft. tt.
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 ft ft.
°Experimental Technology ()Subsidence Control ft. ft.
()Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
°Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) FROM TO DESCRIPTION(osier,hardness,soil/rock type,gala size,etc.)
ft. ft.
4.Date Well(s)Completed: `s9/6 h 23 Well ID# ft' ft' - • - - .
{
5a.Well Location: . •• /�`
flu.- 2, 6(0.2d— ft. ft. ',j; 1 nil A
cility/Owner Name Facility(D#(if applicable)
Physical Address,City,and Zip ft. ft.
/erIA 6 1: 21.RRE)M�ARRKS ��/ /
County Y`v L l Parcel Identification No.(PIN) -rt 1,•.. i 4LC( ` ! 1 f �t ( In
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: e-0r7 '3
(if well field,one lat/long is sufficient) 22.Certification:
1C - 0 3c,2 -ll N--7 G 3Sr/ -2( ( W 'S/ (i
6.ls(are)the well(s)0Pfirmanent or °Temporary 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: IDY.eif<r °No with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out brown 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: � j j SUBMITTAL INSTRUCTIONS
,/
9.Total well depth below land surface: '�L v (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@I00') construction to the following:
10.Static water level below top of casing: (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: V "( (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
re-4-
_ �0 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: �t�V / construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY)VELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I 6 Method of test: 24c.For Water SuDDIV&Injection 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: )7 '
14 Amount: /�1-t/ 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