HomeMy WebLinkAboutWELL-08-2022-178123.TIF WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1. +,a,..,V„�
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1.Well Contractor Information:
Ashley T Moretz 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
2586-A /In rt. 5205-rt. VV in
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap4Ilcable)
Moretz Well and Pump Service LLC FROM TO DIAMETER THICKNESS MATERIAL
fL fi'7 ft. g r in. C p'1,/_rj/ flit,.
Company Name Weili/en
G s/D ,c osed-G+p) tl�s
a0.20���/il8,�.23 FR16.OMIN TO
ING OR'TUB AM(Teothermal closed-loop)
2.Well Construction Permit#. TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft.
3.Well Use(check well use): ft. in
Water Supply Well: ‘ 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
*Agricultural °Municipal/Public ft. ft. in.
Ill Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) tt. in.
II Industrial/Commercial i . Residential Water Supply(shared) IS.GROUT
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 IL a 4 it. AAIUN _ //i�25 42 /j_„-5
&Monitoring QlRecovcry ft. ft. TGC.� �li+G/(
Injection Well: ft. ft.
&Aquifer Recharge ,o'Groundwater Remediation 19,SAND/GRAVEL PACK(if applicable)
III Aquifer Storage and Recovery IlSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
it Aquifer Test DStormwater Drainage ft. ft.
&Experimental Technology Subsidence Control ft. ft
a1 Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
i'Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rack type grain sirs etc.)
/ 0 IL h ft. 0A
4.Date Well(s)Completed/0/fj iy Well ID# /0 ft. ,,3 Q ft. eS..rt" S_.f�� ElL-fV
5a.Well.Location: 50 ft. �y[eeft. 4/.4._O D
ante/ h&11 ft. ,✓t7 �7 ft. C��
Facilityy/OOwner®Name Facility ID#(if applicable) ft. ft.
5'br / / 1M 1Or A-if 1 C4D ,Ja ft. ft.
Physical Address,City,and Zip i s, ft. ft.CoLfr(lt 11/", 6L- 3 72.s7 - y 7 21.REMARI{S
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) �j�� 22.Certification:
3'5r 23020 0 N 24 3.�/9' i'V d 10-4-Z
iy
6.Is(are)the well(s)OPermanent or IO.Temporary Signature of Ce cd Well Contractor Date
By signing this form.I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: 1Yes or °No with ISA NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well constn,ction 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:h SUBMITTAL INSTRUCTIONS
i
9.Total well depth below land surface: 3 4/5- (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 35- (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 (in.) 24b.;for Injection Wells: In addition to sending the form to the address in 24a
Air Rotary above,also submit one copy of this form within 30 days of completion of welt
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) V Method of test: Air Lift 24c.For Water Supply&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: CL Amount: ? 0 Z. completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016