GW1-2021-00879_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
)'e I+D h j—/ ' of s gE E1 . 14.WATER ZONES' >
FROM TO DESCRIPTION
Well Contractor Name (�O Id
a 9 Ls-� ��AR 1 2021 ft. D ft.
ft. fw
NC Well Contractor Certification Number 1 '�tiCi n,�r� n��1CCr�Ecging U13i 15.OUTER CASING for mWti�ased wells OR LINER a" lipble
Company�rron t U e GI CD IJ'Lt11i'�Seef�n FROM TO D R �CIQHFSS MATERIAL
U �. f4 in.
ame
3 / (K'(/ 16.INNER CASING OR:TUBING' eitherntal closed-loo
2.Well Construction Permit#: Ui J (J 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. io
Water Supply Well: 17 SCREEN .
FROM TO DIAMETER SLOT S12 E THICKNESS MATERIAL
❑Agricultural ❑Mu�nicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) of residential Water Supply(single) ft ft. In
❑lndustrial/Commereial ❑Residential Water Supply(shared) dS:GROUT _ .22
__ w` . , k•. ,
Olnigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT MWOD&AMOUNT
Non-Water Supply Well: ft ft. d.,Q l4 Po'A f'e
❑Monitoring ❑Recovery ft. ft
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19 SAND/GRAVEL PACK if a livable
❑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.DRfLLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Coolin Return) ❑Other(explain under#21 Remarks FROM TO DESCRIPTION coke hardy soil/rockfa etc
O ft. ft.
4.Date Well(s)Completed:3-(� Well ID# 3fe (� fL C l It
5a.Well Location: ft S0 ft.
rt.
Facility/Owner Name Jacility m#(if applicable) ft. M
i � ft. ff.
S � nS
Physical Address,City,and fL %
Iran 21 REAIARKSI
County Parcel Identification No.(PIN)
_26(tl Har7ei-\ Drhk, s A d'e.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
N W ( a I
6.Is(are)the well(s): QPermaDent or ❑Temporary Signature o Certified Well Co0actor Date b
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or 11S1Vo ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the 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 construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: c J 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@2M'and 2 100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: G (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: L (�,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AO 4GC� 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental heal department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 1 d Method of test: [ �✓ Permit Program,1611 MSC,Raleigh,NC 27699-16 1 1
13b.Disinfection type: alp Amount: 14
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018