GW1-2021-00498_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
IG cJ A C.7 7 w _. m 2 14.WATER ZONES,
Well Contractor Name
FROM TO DESCRIPTION
�,5�-1-� MAR 15 2021 000 ft 91 ft 0 G ,,�
ft. %
NC Well Contractor Certification Number U 41115.OUTER CASING formulttcasedwells-ORL`I1VER; a licable'':-
i
A on FROM TO DIAMETER TMOCKM MATERW.
1 1/ 1. ft .1/0 fL in > 1j
Company Name
16.-INNER C-A3INGOR�TIJBING�'"eot6ermalelosed-too' ;
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) h- ft. in.
3.Well Use(check well use): ft. h' in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT suz I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public •I ft fit, L in.
❑Geothermal(Heating/Cooling Supply) C�sidential Water Supply(single) fL % in.
❑Industrial/Commercial ❑Residential Water Supply(shared) �418.lOROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q % 06 C 0 Q>n
❑Monitoring ❑Recovery ft. ft Or
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation `19.
❑A uifer Storage and Recovery ❑Salim Bier FROM D/GRAVEL PACK"M ,A ''cable
Q g ery tY FROM TO MATIIUAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL R-
❑Experimental Technology ❑Subsidence Control ft. fL
[]Geothermal(Closed Loop) ❑Tracer 20.'DRILLING LOG attach'additlonal sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardn soilumck type,UWa stM ere
O ft. 3 ft- G S6 t o
4.Date Well(s)Completed: _3� Well lD# ft. �� ft. C
5a.Well Location: M` R' SQ h
&CGV14h N�m�S S� f` a Sft. S 4
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1 S ad r 1/IA 0:L6wn fL ft.
Physical Address,City,and Zip ft. ft.
21.REMARKS
County Parcel Identification No.(PIN) c e I Gr P i'\ h '/ G
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s): C?Permanent or ❑Temporary Signature of Certified well Colluctor Date
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: ❑Yes or QN0 1 SA NCAC 02C.0100 or 1 SA NCAC 01C.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:
S.For GeoprobeMPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (R) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2@1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
If Static water level below top of casing: 00 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
IJwater level is above casing,use
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWI?,Underground Injection Control(TUC)
/� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health 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) 30 1 Method of test: I DL1I Permit Program,1611 MSC,Raleigh,NC 27699-1611
,
13b.Disinfection type: 1 '/(� Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018