GW1-2021-00182_Well Construction - GW1_20210101

WELL CONSTRUCTION RE(` `D(GW-1) For Internal Use On'
1.W Contractor Infor ation:
14,WATER ZONES
FROM TO DESCRIPTION
well cant orN the
/ 1 t t. t. Al 444-1
NC W tractorCe 1 bn dumber 15.OUTER CASING for multi cased wells OR LINER if a likable
FROM TO DLi_'gER THICh,'�ESSI MATERIAL
D CL "L in. (Ic—
Company Name 16.INNER CASING OR TUBING thermal closed-loop)
2.Well Construction Permit#: �,V�/ b�D "1 V b S FROM I To DLl\tETER THtcK.NEss I MATERIAL
List all applicable urll consrntaidn pemits fix.U/C.Ca:mnc State.variance,etc.) it. ft. is
3.Well Use(check well use): R. R. in.
17.SCREEN: ,'
Water Supply Well: FROM -TO` DIAMETER I SLOTSIZE I THICKNESS IATERIAL
Agricultural Municipal/Public in• a ' �/
Geothermal(Heating/Cooling Supply) twesidential Water Supply(single)
Iridustrial/Commtm;ial Residential Water Supply(shared) 18.GROUT `
ti0n FROM TO - MATERIAL S\ CEMENT METHOD&AMOUNT
Inigallon-Water Supply Well: R 0 R..
Monitoring Recovery
Injection Weil: ft. ft.
Aquifer Recharge Q Groundwater Remediation 19.SAND/GRAVEL PACK f a' Itcable
Aquifer Storage and Recovery [DSalinityBarrier FROM 1To MATERIAL ENPLA MENTMETHOD
Aquifer Test [3StonlnvaterDrairaee
Experimental Technology 0Subsidence Control
Geothermal(Closed Loop) QTmcer 20.DRILLING LOG(attach additional sheets if necessary
I FROM TO I DESCRIPTION(color.hardness.solifrocktype.grain Art.etc. .
Geothermal(Heating/Cooling Return) rl Other(explain u der#21 Retnaiks)
4.Date Well(s)Completed: Well ID# t m
a.Well Location: � �
Facility/Owner Name - Facilityl (if applicable) ll
D A16 R
R. R.
Physical Ad tty,and ip
2L.-REMARKS ^ +
q;l 7f
w County Patcel Identification No.(PIN) t
,
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C ifieation:
6.Ware)the well(s)dPermanent or Temporary ignature e Srtified Well Contractor Date
By signing this joint,1 hereby certj that the well(s)Itm(urre)consintcted in accordance
7.Is this a repair to an existing well: QYes or j No with►SA AICA.0 02C.0100 or 15A NCAC 02C.0200 lVell Construction Standards and(hat a
if this is a repair,fell out bioun Weil construction information and explain the nantre of the cope ojthis record has been provided(o the urfl`gn»er.
repair under 021 remarks section or on the back ojthis 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,only l GW-1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may Iilso attach additional pages if necessary.
drilled- SUBMITTAL INSTRUCTIONS
�r1
9.Total well depth below land surface: U (ft•) 24a.For All Wells: Submit,this form within 30 days of completion of well
For nudtiple arils list an depths#V(&trat(example-3« 00 antl j@'U�M'') construction to the following:
to.Static water level below top of casing: 17 (ft.) Division of Water Resources,Information Processing Unit,
ifumer letrl Is above casing.useLl / 1617 Mail Service;Center,Raleigh,NC 27699-1617
11.Borehole diameter: t (in.) 24b.For Iniection Wells: Inladdition 20 sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
t2.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: r 1636 Mail Service Center,Raleigh,NC 27699-1636
On.Yield(gpm)^ Method of test: .4a 24c. For Water Supply&Iniection Wells: In addition to sending the fond to
the address(es) above, also submit one copy of this form within 30 days of
43b.Disinfection type: r` 16! Amount d completion of well construction to the county health department of the county
where constructed.
Fonu GW-I North Carolina Department of Environmental Ota+lity-Division of Water Resources Revised 2-22-2016