GW1-2021-01096_Well Construction - GW1_20210305

WELL CONSTRUCTION RECORD(GW-1) Only:
For Internal Use
1.Well Contractor Information:
c)yI J/4c(5�s A&WATER ZONES,',
Well Contractor Name Ty 1 HR DESCRIPTION
ft
r, ft. fL
NC Well Contractor Certification Number
15.OUTEWEASING(for juld-cmed.-ells ItLae?able))P%I,F= _M IS' UTER To R!WTE: I MATERIAL
We F'rcv)l W Y-- C 0
Company Name I ft- I I
16i INNER CASING OR faeiithirmal closid400p),,-,
2.Well Construction Permit#: (nS—o 00�- FROM I TO I DLAMETER I THICKNESS MATERIAL
List all applicable well construction permits(ie.UIC,County,State,Variance,etc.) % f*- in.
3.Well Use(check well use): % In.
SCREEN '
7
17.
Water Supply Well: FROMTO DIAMETER I SLOT SIZE THICKNESS MATERIAL
OAgricultural E]Municipalftblic ft. ft. in.
0(ivothetmal(Heating/Cooling Supply) [fl;residential Water Supply(single) fL ft. in
Olndustrial/Commercial OResidential Water Supply(shared) 18:GROUT�,:,
ElIrrigation OWells>100,000 GPD FROM TO .MATEIUAL El"LACEM.ENT on&AMO' UNT
Non-Water Supply Well: fL a Z5 ft- it
OMonitoring ORecovery ft. ft. U
Injection Well: it. ft.
DAquifer Recharge OGToundwater Remediation
19.sANDIGRAVELPACK if ippilditlile)
DAquifer Storage and Recovery oSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test OStormwater Drainage ft. fL
OExperimental Technology D Subsidence Control fL fL
OGeothermal(Closed Loop) []Tracer 20.DRIIALJN0LOG(attackaddidimal sheets Knecessary)-'
L f
FROM I TO DESCRIPTION(color,hardness,solt/rock type,grab slze�etc)
DGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) () t. 3 &
f
4.Date Well(s)Completed: (9 / Well]D# 3 % ft.
ft.
Sa.Well Location:
0 ft. n C/
j-0 ft. fL
Facility/Owner Name acility ID#(if applicable) ft. ft.
83 1� knJ C4, ft. ft.
Physical Address,City,and Zip ft. ft.
qke
�121.-REMARKS
— 4 -- —
County Parcel Identification No.(PIN) sc [
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweH field,one lat(long is sufficient) 22.Certification:
-- N W &d- �-)6-d
6.Is(are)the well(s): ffP-e-.anent or OTemporary Signatdm ofCcrtified We Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: 0yes or aN-o 15A NCAC 02C.0100 or 15A NC,4C 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the 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 io provide additional well construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100�
10.Static water level below top of casing: 0 (ft.) 24a. For All Wells: original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use i
11.Borehole diameter: 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 21,699-1636
12.Well constmction method: 9044
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department 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) /s— Method of test:
13b.Disinfection type: qT14 Amount: I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
71