GW1-2021-00332_Well Construction - GW1_20210312

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Informaation�:
1 a KI \O�W 14.WATER.ZONES
Well Contractor Name FROM I TO DESCRIPTION
n �y I l ft. ft. I�/1
IV'IL. ft. ft. ID
NC Well Contractor Certification Number 15.011TER CASING`for multi-cased wells .OR LINER if licable
L- P001'L- 2VMV co FROM fL TO ft. DIAMETER THICKNESS MATERIAL
Company Name 1
C,W O 1" �� 16.INNER CASING OR TUBING eothermal dose d400
2.Well Construction Permit#: 1J�J FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft. ft.
Water Supply Well: 17.SCREEN .
FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
Agricultural VO 'cipal/Public
Geothermal(Heating/Cooling Supply) ential Water Supply(single) ft. ft. io
Industrial/Commercial OResidential Water Supply(shared) 1g:GROUT
it i ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 120
ft
Monitoring %Recovery ft. ft. C
Injection Rech Well: ft. ft.
Aquifer arge Groundwater Remediation
Aquifer Storage and Recovery OSalinity Barrier 19.SAND/GRAVEL PACK fif alieableFROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft, ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG fattach additional sheets if necessary)
Geothermal eating/C oling Return Other(explain lain under#21 Remarks FROM TO DESCRIPTION color,hardnesN soi0rock rain size,etc
ft, ft.
4.Date Well(s)Completed: Well ID# ft. 0 ft. V v1J
Sa.Well Location:
V ' 1 IOM ft. flt. 1J
Facility/Owner Name Facility lD#(if applicable) ft. ft. cni
Physical Address,City,and Zip ft. ft. L y,�� J
WV 0°1 21:REMARKS ,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
N W 1moN Pooh 2 2
6.Is(are)the well(s)oPermanent 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: [)Yes or []No with 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
Ifthis 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#11 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_Ci 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: 'ItS7 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: V (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: 10 (in.) 24b.For Injection Wells: In addition to sending the foam to the address in 24a
f1 to��1 12.Well construction method: above,also submit one copy of this form within 30 days of completion of well
ll C1 1
(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
13a.Yield(gpm) Method of test: � 24c.For Water Supply&Iniecdon 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