GW1-2021-00331_Well Construction - GW1_20210312

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information::
{JU(b��j 14.WATER ZONES
Well Contractor Name F FROM TO I DESCRIPTION
���+ A ft. ft. Q
gyp(
NC Well Contractor Certification Number ? 15.OUTER CASING for mold-case 'wells OR LD%MR if it "ifeable
Ga j zT� FROM ft. TO ft. D TM in. TMCKNFSS MATERIAL
Company Name' '4NN11 r t 3z. V
16.INNER CASING OR TUBING:(geothermal Aosed-loo
2.Well Construction Permit#: J o�- r at) f FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,Count),State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public ft. ft. in]
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
lndustrial/Commercial Residential Water Supply(shared)
18.GROUT: ,
hri atlon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft' a,b ft-
:)Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL PACK applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage
ft. ft.
Experimental Technology ID Subsidence Control
Geothermal(Closed Loop) Tracer .20,.DRII.LING.LOG attachaddid6nal:sheetsffneeess
Geothermal (Heating/Cooling Return) rl Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,sottfroek n Simi ere.
0 It 2- hops ,61
4.Date Well(s)Completed: Well ID# 2— ft. QD it -e
5a..Well Location: ��ft. of ft. 4 f 1,1 �4 C C
�Y 1 alr K 4#110L ft. ft.
�/
Facility/Owner Name Facility ID#(if applicable) ft. ft. � �,
S 3o5 Pb �� LdL ft. ft
k
Physical Address,City,and Zip _T
61 w KIL t d 10 3 3 015, 21`R>:�A1�
—1 tit
County Parcel Identification No.(PIN) y 7:) ( ,_t?nit 1 `
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W � —a�
6.Is(are)the well(s)9(Permanent or Temporary Sigaatarc�ffCcrtifid 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: 13Yes or MN' uith 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out knows: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 i GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: %A0 00 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@I00D construction to the following,
10.Static water level below top of casing: 7.0 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Inlection Wells: In addition to sending the form to the address in 24a
12.Well construction method above,also submit one copy of this form within 30 days of completion of well
F r�
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ( 1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) rL0 Method of test: i b 24c.For Water Supply At Infection 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: s completion of well construction to the county/Ithartment of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016