GW1-2021-03185_Well Construction - GW1_20210625

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: �
-Same s l t 0 WATER ZONES M TO DESCRIPTION
10' '
Well Contractor Name
fr. 6• rt. S"Al
r
fL it.
i
NC Well Contractor Certification Number // 15.OUTER CASING for multi-cased wells OR LINER if a licable
Ca5tc1`de y�I w1,�I q FROM TO DIAMETER THICLGNESS MATERIAL
ft. ft in.
Company Name 16.INNER CASING OR TURING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER TRICICNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) M IL in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17,SCREEN
FROM TO 'DIAMETER SLAT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public W fa It t t in. t�f0 fJG
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. n, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
No`/.-Water Supply Well: fL fL
onitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery El Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer-Test ❑Stormwater Drainage $' IL Ad' fL IPP / (+-ratU t '
❑Experimental Technology ❑Subsidence Control fL M
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING.LOG"attach.additi6nsl sheets Ifnecessa '
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardne soil/rock type,grain size eta
/ 0, ft. 10' ft. GI! -s .-
4.Date Well(s)Completed: lP$tea Weu ID# A(91 e.3-19J. 10.
5a.Well Location: Q fL fL
ft ft. .--
racility/OwnerName Facility ID#(if applicable) ft It.
flQ� IUa4I'tod (ryAd an. SaIt36tt(V., rt ft r
Physical Address,City,and Zip M ft.
-21.REMARKS
County Parcel Identification No.(PIN) DLry i2 v(3 1;011
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification'
3$; 6WgS !$ N -ge.Sab�s3 W (9-$ l
6.Is(are)the well(s): ❑Permanent or 34 emporary Signature oltertified 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: Dyes or Meo 1 SA NCAC 01C.0100 or 1 SA 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
9.Total well depth below land surface: 'W (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q100'and 2@100)
10.Static water level below top of casing: f D (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
`f t 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 7 (in.)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: SB 17 24c.For Water Supply and Opel n-Loop Geothermal Return Wells:Copy to the
e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
DR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Water Wells producing 100,000 GPD100,000 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 Resour`es Revised 6-6-2018