GW1-2021-06945_Well Construction - GW1_20210505

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well
�Contractor Information: C
VC.lrYll`it�>n G116J0C 14.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name
0 ft. Z 10 ft. 1 Idw
klO lQ s - R 2- 1 ID fit, 3-70 ft. fbi 1 w
NC Well Contractor Certification Number 15.OUTER CASING for.multi-cased wells)OR LINER if a rlicable
^ n vl I n •
FRO MTO DIAMETER THICKNESS MATERIAL
fit, in.
Company Name
r1 (� 16.INNER CASING OR TCiBING(geothermal closed-loop)
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2.Well Construction Permit#: �d otO ` 0 4 I U FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well consirvctimt perntiis(i.e.UIC.C'ounly,State, Variance,eic.) fit. Q 1 fit. /_ •7 in. 2`
3.Well Use(check well use): ff, J W fir l7 C in T
Water Supply Well: 17.SCREEN !'
PP) FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Mu Ipal/Public ft. ft. in.
Geothermal(Heatina/Cooling Supply) esidential Water Supply(single) ft. ft. in.
industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri abon FROM TO MATERIAL EMPLACEM ENT METHOD&AMOUNT
Non-Water Supply Well: v fit. CP O ft.
Monitoring Recovery ft. ft. ;
Injection Well:
fit. fit.
Aquifer Recharge Groundwater Remediation
19,SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test nStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) nTraeer 20.DRILLING_LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soilh»ck e,grain size,etc.
CP Geothermal(Heating/Cooling Return) �1 _1 Other(explain under#21 Remarks) ft, 3(0 ft. 04 Q ve)!Cbu V-d ep-A
4.Date Well(s)Completed: �dJ' « ! Well iD# ft, 41,.El�-ft' 6�ra'r%
5a.Well Location:
L ft. I ft.
-!r!-•1 n T ft. fit. e p a-
Facility/Owner Name Facility ID#(ifapplicable) FE
to
3 ' Lau nm LaZ Cn r�i[Q�G Z� 1 1 ft. ft.
n
Physical Address,City.and Zip 'f rr __ fir. ft. ;j 5 2021
n, 9(0o 9424V 21.REMARKS
prc,,cessinig. ,.M
County Parcel Identification No.(PIN) 6,r ,+{K V
VV v�+
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Cer ication:
35",31' 3.0 7.89 N SZo 43 ' -41. 34'48-9 w
S= V
6.Is(are)the well(s) ermanent or Temporary ignature of Certified Well Contractor Date
by signing this,inm,I hereby certify that the ire/I(s)was(were)constructed in accordance
7.Is this a repair to an existing well: l'es or _'. o wilh 15A NCAC 02C.0100 or I5A MCA('02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction in/orntation and explain the nature of the copy of this record has been provided to the w ell owner.
repair under r11 remarks.section or on the hack of this.form.
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 site details or well
construction-onk I GW-i is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: �1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: -I (ft.) 24a. For- All Wells: Submit this forin within 30 days of completion of well
Far multiple hells li.oi all depths ifth fereni(cxmnple-3 a 200'and 1 N00') construction to the following: k
10.Static water level below top of casing: 19 d (ft.) Division of water Resources,Information Processing Unit,
if water level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
f '
11.Borehole diameter: • Z S (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
�OY� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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) Method of test: t 24c. For Water SunDly& Iniectio'n Wells: In addition to sending the form to
1- 1 the address(es) above, also submit'one copy of this form within 30 days of
U13b.Disinfection type: JCW,� Amount: � 7G'�b( completion of well construction to`the county health department of the county
where constructed.
Fonn G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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