GW1-2021-00330_Well Construction - GW1_20210312

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1:Well Contractor Information:
'T-o' 0 Y 1 Pb I�J 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
aa� a it. �0
ft, ft.
NC Well Contractor Certification Number / 15.OUTER CASING for multi�eusedwells OR LINER if a cable)
r n n �' 1 e� FROM TO DIAMETER THICKNESS MATERIAL
N �— CJPLAMC �V v ft. 6 ( ft. in.
Company Name 1
M INNER CASING OR TUBING(geothermal closed-loop)
r, _ _
2.Well Construction Permit#: W ` O - o x FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
Agricultural unicipal/Public ft, ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R, ft. in,
Industrial/Commercial Residential Water Supply(shared) 18.GROUT.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD 6c AMOUNTNon-Water Supply Well: 0 ft. a tt. dK+0 h I� ea
Monitoring [`Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK ff lY 1(cable ,
Aquifer Storage and Recovery OSalinity Banter FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLINGLOG attach additionalaheets if.utcess
Geothermal (Heating/Cooling Return) rl Other(explain under#21 Remarks) FROM TO DESCRIPTION co hardness,soft/rack type,greln stze,etc.
0 iL ;" rt. t6 0 So I
4.Date Well(s)Completed: 3 - - i Well lD# I
it• So ft' I Q
5a.WellLocation: 5 �ft. 3 d ft. ( oe-(r—
S Iel Ie V e �/A q�t"- \ ft. ft.
Facility/OOwner�N+�a'me Facility ID#(if applicable) R' ft. --�u a9 5 4,
ft
J V J A v wn 1�1/ }a tr . ft.
PMAddress,City,and Zip Il ft ft. Nl Ali
e N L �/�7 2t.REMARKS'. ee
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laVlong is sufficient) 22.Certification:
N W
6.Is(are)the well(s) Permanent or Temporary Signature of ,crtified 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: [3Yes or No with ISA NCAC 01C.0100 or 15A NCAC 01C.0100 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 4111 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-I 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: 3 ,40 (f1-) 24a. For Atl Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: D.0 (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: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
rG l 4 r above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: l 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: r 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) t Method of test: b w 24c.For Water Sunnly&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: Amount: completion of well construction to the county health artment of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016