GW1-2021-02614_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
ZT&"' 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor
^Name 6 ft. ( 1 TTL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
t ool(p \ell �- FROM TO DIAMETER_ THICKNESS MATERIAL
V` r W l rlv ft. ft. in. f $ 'V
Company Name a
� 16.1NYER CASING OR TUBING etrthermal closed-loop)
2•Well Construction Permit#: D ( � 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.
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public ft. ft. in,
Geothermal(Heating/Cooling Supply) 6JRcsidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
-)Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O tt. so—ft. bt: hl�"L f a Ur
Monitoring DRecovery tt. ft.
Injection Well: ft. ft.
fL
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK a IcalbleL_
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft• ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets If necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTIO�N color ha soil/rock type,grains etc.
/ 0 ft. 2- & 50ll
4.Date Well(s)Completed: 6-- I Well ID# 1 ft. ft. GI21+('
5a.Well Location: 0 ft• 28A ft f" G
I I N S 14 it. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
b'r h
i
Physical Add ss,City,and Zip
P'( 4 S 3 3� 1 l' 21.REMARKS
County Parcel Identification No.(PIN) tJn11
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
int��m3tx�n Qn
(if well field,one latlong is sufficient) 22.Ce 'ficati0n'L�
N W 21
6.Is(are)the well(s)dpermanent or OTemporary SigAdfure of(fertiffed Well Contractor Date
By signing this form,1 hereby certify that tine well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or 46No with 15,4 ACAC 02C.0100 or 15A NCAC 01C.0100 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#11 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 to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I
�— -y SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ar0 0 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: G (in.) 24b.For Iniection 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: a �4 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: L ( 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test: U 1 W 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: 7/ completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016