GW1-2021-02510_Well Construction - GW1_20210505

a.
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Intor lion:
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Well Contractor Name ? FROM TO DESCRWRON
22 r p r, v 202
5 ,oft S"' / ft 2 M
yJl7� 1v1y1 l?'y, ft. R
NC Well Contractor Certification Number
15.iOUTER-CASING formul&4:'sed'we16 ORLINER If -
(/ FROM To D THN3INFSS MATERIAL
y ft ft in. g G a(Va d
Company Name
1&INNER GASING OR TUBING ttiernui dose8-i ,s .,_r..
2.Well Construction Permit#: I J 7 ! 70 20 FROM TO DIAMETER I TINC 0MS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) & R
3.Well Use(check well use): ft ft in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE I THICTfl+MS I MATERIAL
Agricultural [3Municipal/Public 0 ft. ft.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft & in.
Industrial/Commercial Residential Water Supply(shared)
a8.:GROUT >...
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 & 2-0 ft. U
Monitoring ORecovery ft ft
Injection Well:
ft ft
Aquifer Recharge 13Groundwater Remediation
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test []Stonnwater Drainage & ft
Experimental Technology D Subsidence Control ft ft
_ Geothermal(Closed Loop) Tracer -;20 10D ING LOG fattach idditi nil!sfiei3ts'if
Geothermal(Heating/Cooling Return) ,Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/reck im grain sim etc.
ft S'o ft
4.Date Well(s)Completed: 21 �(/ Well II)1# ft- 61 ft- 0.
5a.Wellll Location: w ft � — ft61,74 e
LI JGG I y(C�r ft ft
Facility/Owner Name i Facility ID#(if applicable) ft ft
W2��' &u r wade ��esf ft ft
Physical Address,City,and Zip & ft
21:REMARKS . �.
County Parcel Identification No.(PIN) ardFLI 1 1 P_
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certificati n:
N W l
6.Is(are)the well(s)OPermanent or 13Temporary Signature ofCertified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or /2 No with 15A NCAC 02C.0100 oro15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back 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 toprovide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this foIin within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@2000'and 2@1001) construction to the following: f
10.Static water level below top of casing: 6✓ {t
( ) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use /+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method,
�/
c{(^Y above,also submit one copy of this form within 30 days of completion of well(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm)�< Method of test: 0 i 24c.For Water Supply&Injection Wells: In addition to sending the form to
p the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: D 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