GW1-2021-00629_Well Construction - GW1_20210326

1 1111\1 VI I11
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:�TaJJn 1 Ot1t�e� 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
t 7,y0 ft.
aa7� R. ft.
NC Well Contractor Certification Number
15.OUTER CASING Ifor multi cased wells I T LINER cable
FROM TO DIAMETER T®CKNESS MATERIAL
1 —�— p D. R. ` in. V f✓
Company Name
a o 1 I SD h C�, 16.INNER CASING OR TURQYG eothermal daaedJ
2.Well Construction Permit#: FROM TO DIAMETER TIDCKNFSS MATERIAL
List all a applicable wel/construction milste.VIC,County,State, fL R. In.
PP Per ( ry, Variance.etc.f
3.Well Use(check well use): R. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSITE TmL•KNESS MATERIAL
Agricultural Municipal/Public ft. it. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R. ft In.
Industrial/Commercial ®Residential Water Supply(shared) 19.GROUT
irrj ation FROM TO MATERIAL L EMPLACEMENT M LACEEETfIOD&AMOUNT
Non-Water Supply Well: G ft. Z 0 ft. ♦t h LPL• ret,(/
Monitoring Recovery D.
Injection Well:
Aquifer Recharge ©Groundwater Remediation
19.SAND/GRAVEL PACK(Ifa Ileahle
Aquifer Storage and Recovery Salinity Barrier FROM 1 TO MATERIAL j EMPLACEMENT METHOD
Aquifer Test ©Stormwater Drainage ft. ft.
Experimental Technology ®Subsidence Control ft. ft.
Geothermal(Closed Loop) ©Tracer 20.DRILLING LOG factsch additional sheets if necessary)
Geothermal (Heating/Cooling Rehm) nOther(explain under#21 Remarks) FRONT TO Woa7RIPTON color lo.ohen.witiroca tvae,min sise,do
0 R. Z ft. O $o 1
4.Date Well(s)Completed: Well ID# 17 ft' D T" S&P16 K4,
So� 'WepLocatlan: _f!o ft. ace ft• �it f 'r k
(p ( v ft. ft.
Facility/Owner/Owner Name
Facility ID#(if applicable) ft. h.
goo-2- 8('4 e' // In. ft. ft.
Physical Address,City,and Zip Lt f' ft.
W l�l•foti 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one In/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s)OPermanent or ©Temporary Signs ur o citified Well Coiltrievor Date
By signing this form,I hereby certify that the neD(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or [:)No with 15A NCAC 02C.0/00 or 15A NCAC 02C.0200 Well Cousouction Standards and that a
If this is a repair,fell out known well construction information and explain the nature of the copy of this record has been provided to the well owner,
repair under 021 remarks.section or on the back of this form.
13.Site diagram or additional well detalls:
g.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled. I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (fi.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells/istull depths efdl$erew(example-3Qu200'and 2g100') consu etion to the following:
10.Static water level below top of casing: �`� (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use jL 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
I/f,fir,✓,ter above, also submit one copy of this form within 30 days of completion of well
12.Wen construction method: VV 1 ' I construction to the following:
(i.e.auger,rotary,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) L4 Method of test: 24c. For Water SaDOIT&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: I �'' �� completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2.22-2016