GW1-2021-02155_Well Construction - GW1_20210505

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Inform
m
f}V 14.WATER ZONES
FROM TO DESCRIPTIO'
Well Contractor Name
A tt. ft.
5 " ft. ft.
I---NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER if a Gcable
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in. O C/
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
VV
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State. Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural Dunicipal/Public ft. ft. we
in. "ft/
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) f[. ft. in,
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEME'T METHOD&AMOUNT
Non-Water Supply Well:
Monitoring X, ORccovery
Injection Well:
Aquifer Recharge roundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recove Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStonnwater Drainage tt. tt. �✓
Experimental Technology Subsidence Control
Geothermal(Closed Loop) cer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soillroek rain sire.etc.)
Geothermal(Heatin oling Retnurn)Q� Other a in under#21 Remarks) ' ft. ft. A
4.Date Well(s)Completed: 3 `v I?, Well iD# It ft. 1 ft aiow un
5a.Well Location: ft. 2q ft.
� ---tr�'-w�(�• ft.
L
tacility(OwncrNane Facility f.
a ev) �a 11 NI A W .
ft. ft.
Ph y icaI Address City,ani Zip
21.REMARKS
2021
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: `t• '^ ^j'Oil
6.Is(are)the well(S) Permanent or Temporary Signature ofCertifi d N ell Contractor Datc
Av signing this form,i herehr certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or §No with 15.4 NC4C 01C.0100 or 15.4 NC.4C 01C.0100"'ell Construction Standards and that a
Ifthis is a repair,,ill out knoxn well construction information atul explain the nature of the copy of this record has been provided to the well owner.
repair under#11 remarks section or on the back gjthis dorm.
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,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: M n SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: U �v (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdij)erent(example-3(,100'and 1(tr)/00') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If rater level is above casing,use..+-D 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: x^ (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: vrkaa construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
OR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 115 Method of test: 24c.For Water Supply& Iniection 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:��� 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