GW1-2021-03142_Well Construction - GW1_20210625

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.IVATERZONES
Well Contractor Name FROM 1170 DESCRIPTION
�C(��,,(( `{ fL ft. j
1(U- 438 ft. ft.
NC Weil Contractor Certification Number !
15.OUTER CASING(for mtilti-cased ivel[c OR LINER Gf applicable)
c ! FROM TO DIA11fE1ER THICINESS 5UTERLIL
Company Name 1 ft. t [t. al. io
16.INNER CASING OR TUBING(geothermal cued-log
2.Well Construction Permit#: `� '7S f FROM TO I DURIFTPER I TIRCKNESS r*UTERIAL
List aft applicable%cell construction pernlits(i.e.UIC Crntnn:state.Variance,etc.) Ft. ft. in.
3.Well Use(check well use): ft- ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE TMCJLX&S MATERIAL
Agricultural DMunicipal/Public D fL in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industr:Commercial Residential Water Supply(shared) 18 GROUT
Irri ation FROM To MATERIAL EMPLAC&tilENTAMMODgAMOUN17
Non-Water Supply Well: ft. t ft. r
- - - - -- - - -- ---— -_-- -
zrrn
Monitonng DRecovery ft. ft.
Injection Well:
Ft. tt.
Aquifer Recharge oGroundwater Remediation
19.SAND/GRAVEL PACK(if a licable)
Aquifer Storage and Recovery Salinity Barrier FROM TO I 6lATERrAt I rairPLACEhIENT METROD
i-Aquifer Test DStormwater Drainage R• n•
Experimental Technology oSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Hearing/CoolingRetum) Other(explain under#21Remarks) FROM To DESC ON(ro].,,,brd�,.IUmk min-ie,eta)
f ft. c ft.
4.Date Well(s)Completed: Well ID#dad&ww l ft. r it.
5a.Well Location: G D• 6 R•
'7D��� �5
Facility/Owner Name ` Facility`ID#(if applicable)
ION
�—Ph, ft. ft.
AJJress.City.and Zip ljtjlt
21.REMARKS
►% p;N
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreesfminutes/seconds or decimal degrees:
(if well field,one lat/long 6 sufficient) 22.Certification:
E
N W
6.Is(are)the well(s))OPermanent or OTemporary Sig ature of Certified Well Contractor Date
Br igning this fonn,1 herebr certi i•that the i ell(s)i at(here)constructed in accordance
o % do ISA NCAC OZC.UJ00 or ISA IVCAC!)2C.02t70 Nell Construction Standards and that n 7.Is this a repair to an existing well: 'OYes or
If this is a repair,fill out known hell construction i ifontratiotr ti erplain the nature of the copy of this record has been provided to the it-ell anmer.
repair corder t21 remarks section or an the back of this form. 23.Site diagram or additional well details:
S.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
constructiop.only i GW-I is needed. Indicate TOTAL NUMBER of wells constriction details. You may also attach additional pages if necessary.
drilled: ISUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:0 (fL) 24a.For All Wells: Submit this form within 30 days of completion of well
For-nnldple wells list all depths if different(example-3@200'turd 2 a 1001
construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If%rater level is above casing.use-+'• 1617 Mail Service Ceti'teh,Raleigh,NC 27699-1617
11.Borehole diameter: Le (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
�q S `` above.also submit one copy of this foim within 30 days of completion of well
12.Well construction method:Yt 1� 1 L w W l�l l 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: 1636 Mail Service Center.Raleigh,NC 27699-1636
139.Yield(gpm) �� Method of test:J[1 24c.For Water Sunnly&Iniectio I Wells:!In addition to sending the form to
the address(es) above, also submit Done copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the[county health department of the county
where constructed.
Fran rmw-1 Nnrth Cnmlinn rmenanment of Fnvimnn nlni Ounlinv-l)ivi%inn of\Vaster Resnttrces I Revised 2-22-2016