GW1-2021-00533_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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14.WATER ZONES
Well Contractor Name 4 , 5 � FROM TO DESCRIP rION
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ft. ft.
NC Well Contractor Certification Number �y tt^vi l i F���C�
•,i.,,d., t5.-OUTER:CASING for math=cased>wells�ORLINER' -a` licabk`
r. /•,, ��C(, C/� µme- a Nam/ FROM TO D R TffiCIINFSS MATERIAL
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Company Name
D �" 16INNER CASINGOR`T[IBING''eotherotal closed-loo "-- -
2.Well Construction Permit#: ` l q N Z� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(1.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 SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) GlUe-sidential Water Supply(single) ft. &
❑lndustrial/Commercial ❑Residential Water Supply(shared) z18 GRDUT_
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT TROD&AMOUNT
Non-Water Supply Well: 0 ft
❑Monitoring ❑Recovery ft. ft
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation
19 SAND/GRAVELPXCKtif,i lie ble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control IL ft.
[]Geothermal(Closed Loop) ❑Tracer 20.DRUAMG`LOG attach'addltiooelsbeets if necessary)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rack ftype,grain size,eta
C) ft ft. O SQ At
4.Date Well(s)Completed: —5- Well ID# `� ft. a 0 ft. C C.
5a.Well Location: U ft U ft. .50n
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Facility/Owner Name Facility ID#(if applicable) ft. ft.
1 ui I � / i I ft. ft
Physical Address,C7ity,and Zip % ft
lIi�4 k1 21:REMARKS
County Parcel Identification No.(PIN) Gr 9
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
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6.Is(are)the well(s): 013'e-rmanent or ❑Temporary Signature of Certified well Con&actor 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 941 15A NCAC 02C.0100 or 15A NCAC 01C.0100 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 thisfeum.
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: 24.SUBN=AL INSTRUCTIONS
9.Total well depth below land surface: J 0 1�f (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 1Qa 100�
10.Static water level below top of casing: d b (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If"ter level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
{ Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:tG � 24c.For Water SUDDIV and Open-Loop Geothermal Return Wells:Copy to the
(i.e.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) t Method of test: 0 Permit Program,1611 MSC,Raleigh,NC 27699-161 l
13b.Disinfection type: 14T4Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018