GW1-2021-03186_Well Construction - GW1_20210625

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Informatiion:
10,146 S,�l WATER ZONES
FROM TO DESCRIPTION
"'ell Contractor Name 3.D s q D, � � /G
(,
1 1 i 3+' f J ft. -go,
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER a lieable
Gas�,de. d� f II t FROM ft TO ft DIAMETER
THICKNESS MATERW
1 { ��
Company Name 16.INNER CASING OR TUBING fecothermal 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. ft. r°'
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public t fL r ft. '&I in. ����D �Gh go PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) O` fL ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18i GROUT
OIrrimation ❑Wells>100,000 GPD FROM TO MATERAAi. EMPLACEMENT METHOD&AMOUNT
No -Water Supply Well: ft. fa
NA4onitoring ❑Recovery ft. ft.
Injection Well: fL ft
❑Aquifer Recharge El Groundwater Remediation
19i SAND/GRAVEL PACK if a0plivable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL 34' ft '
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets lf necessa
FROM TO DESCRIPTION color,hardness soWrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0� ft. / , fL G S .vD
4.Date Well(s)Completed: (�'Q-a Well lD# &B J2,t fL 30' fL S a/ — -lay
Via.Well Location: ft. ft.
It. ft. �
Facility/Owner Name Facility ID#(if applicable) It. ft. �
�l4 itla�I'•od &It,�,r1�1 AD. Sa1136t:�v . rUL ft ft r 2 z
Physical Address,City,and Zip ft. ft.
'21.REMARKS''' In ..t
2owQ,n qb9 e61-! v�
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.Certification:
35; 6y6 OX19 I N -Sra-5-161I a I W (9-1-7/
6.Is(are)the well(s): ❑Permanent or VImporary Signat4sAfCertified 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 IR'NO I5A NCAC 01C.0100 or I5A NCAC 02C.0100 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: 0 ifh) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dii erent(example-3Q200'and 2@1001
t 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: J'B (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
7V t I' 24b.For Iniection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: SB�fI�. 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
rOR 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 Resources Revised 6-6-2018