GW1-2021-00623_Well Construction - GW1_20210326

1 III III VIIII
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1 Well Contractors Information:
A� Som \O��`.l. 14.WATER ZONES
Well Contractor Name FROM TO DESLTIIPTION
' e ft. oft. re
ft. O.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells DR LINER If a Ocable
\Nu Co FROM TO 11 D AMETEK THICKNESS MATERIAL
0tt. b/ ft. in. ..�"�
Company Name
m INNER CASING OR 7L'BIN eothermal Glace ps
2.Well Construction Permit#: L FROM TO DIAMETER THICKNESS I MATERIAL
Cut all applicable unll cowouct/on permits(i.e. UIC,Couny,State, Variance,eta) ft.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOTSIZE TIIICL^QESS MATERIAL
Agricultural []Municipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) WesideDtial Water Supply(single) lo.
Industrial/Commercial ©Residential Water Supply(shared) IR.GROUT
-)Irrigation FROM TO MATERIAL EMPLACEMENT METHOD A AMOUNT
Non-Water Supply Well: 0tt. tt. heAholft
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation 19.SANDlGRAVEL PACK ifs Icable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METBOD
Aquifer Test DStormwater Drainage ft. R.
Experimental Technology ©Subsidence Control ft. I ft.
Geothermal(Closed Loop) ElTracer 20.DRILLING LOG smeIt additional sheels if necessa
Geothermal(Heating/Cooling Return) nOther(ex lain under#21 Remarks) FROM To ft. DESCRIPTION color h.rda wmlaen m:I err.
1 R.
4.Date Well(s)Completed: L 2'1 Well RM ft. p H•
5a.Well Location: J6 Q
ft. R. e
Mm W T-ro ft. ft.
Facility/Owner Name Facility
tylEm(ifeppliceble) ft. ft.
1 'le r �{1�G� \�•'� �G1lV�O1V tt R.
Physical Address,City,and Zip ft. ft,
1�J 'l 21.REMARKS MAR
County �,�n k Parcel Identification No.(PIN) MAR
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one laClong is sufficient) 22.Certification:
N W
6.Islam)the well(s)�ermanent or ©Temporary Signature of Certified Well Contrutor Date
By signing this form,I hereby cert�that the usll(s) was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or o with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
If this is a repuin fill out knoves well conerruction information and explain the nature o(the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back afthis form.
23.Site diagram or additional well details:
g.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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: j ((21 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 'UO (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wets tut all depths fdiffie ent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 7 V (ft.) Division of Water Resources,Information Processing Unit,
If aster level is above casing,use'+"^ 1617 Mail Service Center,Raleigh,NC 27699-1617
'
11.Borehole diameter: W (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
ward above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: / construction to the following:
ii,e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 1 Q U/ 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this fore within 30 days of
1
13b.Disinfection type: �r Amount: I I i completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality.Division of Water Resources Revised 2-22-2016