GW1-2021-00844_Well Construction - GW1_20210322

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I Well Contractors Infoiorlmartion:
A� \ol)l som .L 14.WATER ZONES
Well Contrialim dame ypa FROM To DESCRIPTION
1�_ 1� " YT O ft.
1'1ft.
. V ft.
NC Well Cmmacror Certification Numbet 15.OUTER CASING the,multi-easedweW ORWNER ifs able
nm 'c Gy-n� FOOD MW Co FROM TO DIAMETER TmCKNESS MATER
R. /6' ft. in. y r
Company Name f
16.INNER CASING OR TUBIN eothermal closed-too
2.Well Construction Permit as 5 L I mom TO DIAMETER THICKNESS MATERIAL
List all applicable we11 cowtracnon permits o s. UIC.Count),State. Variance,eta) ft. H. I in.
3.Well Use(check well use): ft. ft. in
Water Supply Well: 17.SCREEN
FROM I TO I DIAMETER I SLOTSIZE I THICKNESS I MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(HeatingfCooling Supply) Wmidential Water Supply(single) ft. ft. in.
IodustrialiCommercial DResidmoal Water Supply(shared) I&GROUT
1m 3tinn FROM TO MATERIAL EMPLACEMENT MEF[IOD&MIOUNT
Non-Water Supply Well: ft. ft B V t
Monitoring Recovery
rAquif�
ell:echarge [3GmundwMer Remediation19.SAND/CRTO PACK bleorage and Recovery �Szlinity Hurtles FROM TO MATERIAL EafNdCFAtENT METROD
st �Starmwater Drainagetal Technology ®SubsidenceControl ft. R.
l(Closed Loop) Tracer 20.DRILLING LOG atach additional shau Hl(Heating/Cooling Return) Other(tx lain under#21 Remarks) mom To DESCRIPTION cabs ar bds smvr k in. ete.
�1 ft. it. .4
4.Date Well(s)Completed: L Z� Well ID# ft' 0 ".
5a.Well Location: to u. D' e
Mm W T-To ft. D'
Fitediiry/Owner Name Facility true(ifapplicable) H. H.
1 'Lr -
Physical Address,City,and Zip
R. ft
`
F L�/n 21.REMARKS 1v,H
County 7" Parcel tdcntifieation No.(PM)
5b.Latitude and longitude in degreeg/minutes/seconds or decimal degrees:
(dwell field,one IaUlong is sufficient) 22.Certification:
N W
6.Islam)the well(s)UPermanent or OTemponry Signature of Certified well Contractor Date
By signing this form, I hereby certifv that the uefl(s)was(were]constructed in accordance
7.Is thin a repair to an existing well: QYes or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constsucrion Standards and that a
If this 6 a repair fill out known well construction information and explain the nature ofthe copy alibis recto has been provided to she well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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 cr well
construction,only 1 GW-I is needed. Indicate TOTAL NlUrMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I ((I2 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 'UD (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'arndd'(m1001 consWction to the following:
10.Static water level below top of casing: V (ft.) Division of Water Resources,information Processing Unit,
Ifuater level is above easing,use"*' 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: vt/ (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
rvarYl above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: // construction to the following:
(ie.auger,many,cable,direct push,etc.)
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 tent: O 24c.For Water Supply&Iniectlon Wells: In addition to sending the form to
the addresses) above, also submit one copy of this forth within 30 days of
13b.Disinfection type:—ERAmount:- ( i6: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvannmental Quality-Division of Water Resources Revised 2-22-2016