GW1-2021-01407_Well Construction - GW1_20210210

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
JAc®b S I
FROM TO DESCRIPTION
Well Contractor Name
ft.
L-5- /4 ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased'wells)ORiLINER(if a Iicable
FROM TO DI E .1 THICKNESS
ny�1 M TERIAL
►�1 r 2l'n 1 t 1 e l CC ft. ft. in. f(
Company Name v
G_ f 7 0 S/� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: I"7/.J< FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(itt.U/C,County, late, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Su 17.SCREEN
Supply Well: FROM TO DIAMETER 1 SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Mre_�sidential Water Supply(single) ft. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METH &AMOUNT
Non-Water Supply Well: © ft. ft. G M6 Ls
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock rain sin,etc.)
ft. ft. LIP
6 t
I
4.Date Well(s)Completed: Well ID# ft. ft. Q
Sa.Well Location:
6 ft. ft. 3a-11
ft. 6_511,
ft. `r Q n If --
Facility/Owner Name Facility ID#(if applicable) ft. ft.
r'J�GS FCerA)9Q(`6 C6y►' Uff ft. ft.
Physical Address,City.and Zip ft. ft.
WC1 Y e 21.REMARKS /�
County C� Parcel Identification No.(PIN) e C a~ m ri,)4 d-e-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one hullong is sufficient) 22.Certification:
N W C a
6.Is(are)the well(s): 015er.anent or ❑Temporary Signature of Certified Well Con for ® Date
�� Ny S this form,I hereby certifj that the ire//(s)was(urre)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or .L�IIVo is�'� t1�q�!�•02C.0/00 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain'p, ,,.,a�he.�9 'wfthi3!record has been provided to the well owner.
repair under 21 remarks section or on the back of this fornn.
!� May
or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having tIV in the 1 "-1 M ay use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Q.ver'in Remarks Box).You may also attach additional pages if necessary.
drilled: '`2¢.-SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1.°`"(ft.)
For multiple wells list all depths ifdifferent(example-3(a 200'attd 2@/00') Submit this GW-1 within 30 days of well completion per the following:
+•)
249. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: d (ft*) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use
11.Borehole diameter: (in.) 24b. For Injection Wells: Copy to!DWR, Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: (\D IQ��� 24c.For Water Sup v and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health epartm i ent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
/ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) l Method of test: t�W
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018