GW1-2021-03184_Well Construction - GW1_20210625

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
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h 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
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NC Well Contractor Certification Number 15 OUTER CASING for multi-eased wells OR LINER ifs lleable
Gas�de ��1'I I n9 FROM TO DIAMETER THICE7VESS MATERAAI
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in.
Company Name 16.1NNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft• It. in.
3.Well Use(check well use): tL ft. in.
Water Supply Well: 17,SCREEN ".
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public Jt/' rL ��'fL It in. � ��� Scy yp ve-
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
n-Wa
ter Supply Well: fL Lto
Monitoring ❑Recovery It. fL
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
,19;SAND/GRAVEL-PACK if applicable
❑Aquifer Storage and Recovery ❑Salinity Barrier TO MATERLIL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage g' fL 3Q• fL F,P avr
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer ;20.DRILLING LOG attach additional sheets if necesse
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness soll/rock n size eta
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4.Date Well(s)Completed: We11ID# fFDl03 -03 0, rL ID 10, tt lal it .� - I
5a.Well Location: 1q, fL 30, fL S —L la
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racility/Owner Name Facility 1D#(if applicable) it. it q T-
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11 a5 A OWI t,,nml kdPJ 4- Shc;5bUty At. rL rL 021
Physical Address,City,and Zip �/ fL it. I r
t�+B Wan L(of (17 7 21.REMARKS
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County Parcel Identification No.(PIN) `';3tionpCb^'§Stf1i� 111
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifica
3-'!r GSo3Ya-7 N 40.5S 4 a57 J_ wAA�� ,
6.Is(are)the well(s): ❑Permanent or 2 emporary Sign o Certified Well 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: Oyes or Vlo 15A NCAC 02C.0100 or 15A NCAC 01C.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 to provide additional well construction info
construction,only 1 GW-1 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
3
9.Total well depth below land surface: (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(a3200'and 1®100)
(L�' ► 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter: (in.)
24b.For Injection Wells: Copy,to DWR,Underground Injection Control(IUC)
i
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: S WA L 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
"e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
I
DR 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:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resou'es Revised 6-6-2018