GW1-2021-02663_Well Construction - GW1_20210620

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ®�
ell \d in 5kE 1 C'kl0\ ' �(��� 14.WATER ZONES
At:�,r
W Contractor Name riX FROM TO DESCRIPTION
�vN ti � I 5 ft. y© ft ,� M
QcQoe;o� Zv ft- 205 ft.
NC Well Contractor Certification Number n�,lOr1�SgC'S 15.OUTER CASING for multi eas welts OR LIMIER rf a Gcable
( ,_Q n[ 'lr�� �Q_Vn FROM TO DIAMETER THICKNESS MATERIAL
Company Name J �V h.l 7�l`I +- I fL ft ( in. ' f
16.INNER CASING OR TUBING eothermal dosed-loo
2.Well Construction Permit FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,ere.) ft. ft in.
3.Well Use(check well use): ft. ft in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑M icipaVPublic ft. ft in.
❑Geothermal(Heating/Cooling Supply) esidenhal Water Supply(single) ft D• in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
olrrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Qt�Q rt' Zb rt ),-A V;;
❑Monitoring ❑Recovery ft. fL 7C A
Injection Well: ft. ft
OAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑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 ft. ft.To DESCRIPTION color,hardness,soil/rock rain sae,etc.
,
4.Date Well(s)Completed: 5 r +Z 2 Well ID# ft. ft.
5a,Well Location: ft. rt.
.t k ft. ft.
Facility/Owner-Name ^� /� Facility IDk(if applicable) ft. ft.
IUD In .�,o� 'PI&C-1 ft. ft. —
Physical.Address,City,and Zip ft. fL
i s\!L k7t/f��' 3 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
(if well field,one lat/long is sufficient) 22.Ce Ieatfon:
N W �/Z-Z
6.Is(are)the well(s): ermanent or ❑Temporary T3.Sitediagrom
ofCertiSed Well Contractor Date
g thisjorm.I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o C 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill oul known well construction information anti ecplain the nature of the ord has been provided to the well owner.
repair under 21 remarks section or on the back of thisjorm.
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 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: 350 (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(example-3@200'and 2@10(y)
24a, For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Z V (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1f water level is above casing,use"+"
11.Borehole diameter: (in,) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ce4 w 24c.For Water Su I and O en-Lon Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push etc.) county environmental he th 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) Method of test: �}
13b.Disinfection type: ( Amount: I t
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018