GW1-2021-03188_Well Construction - GW1_20210625

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor In__f�-orrm�cation:
�QAKJ S�n. '14.WATER ZONES
FROM TO DESCRIPTION
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Well Contractor Name i ft is• rt c
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1 1 7 g- A ft It.
NC Well Contractor Certification Number 15r OUTER CASING(for ulti-cased wellsy OR LINER if a lleeble
CaS�G�(t jar t,L 1 t' q FROM TO DIAMETER TMME55 MATERIAL
tJ ft ft. in.
Company Name 16.INNER CASING OR TUBING eother al closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): tt rt in.
Water Supply Well: 17,SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public I ft gsI rt a., in. (9,0r0 D (/L
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft in,
❑Industrial/Commercial El Residential Water Supply(shared) 10 GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
NoJtr�Water Supply Well: fL ft
onitoring ❑Recovery fL fL
Injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a Qcable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage (3 % 05t ft G-P' — 5,f
❑Experimental Technology ❑Subsidence Control fL ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional'sheets if necessary)
❑Geothermal(Heating/Cooling/Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION Other
hardness,soiUrock ins eta
D, ft 1Z f ft L�a _, s �
4.Date Well(s)Completed: 19���—�1 Well ITD# 1+binl•D It ft rL S;
5a.Well Location: ft fL
lion: r
_{5 . 4 ft. ft t
Facility/Owner Name Facility ID#(if applicable) fL IL
N 5 A16+,e J &ailed !z>n. Saltsburu.^Jc ft. ft JUN 2 5 2021
T— fL fL
Physical Address,City,and Zip n j
21 REMARKS"'' C1iG i, ttvs
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:
eb//a— N -SO.59610-5 W
6.Is(are)the well(s): (Permanent or ❑Temporary Signature erti led 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: ❑Yes or '?No I5A NCAC 02C.0100 or 1 SA NCAC 02C.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
ter' /
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 ifdierent(example-3@200'and 2@100)
.Static water /a , 24a. For All Wells: Original form to Division of Water Resources (DWR),
10 ater level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If 10 Static
level above casing,use
11.Borehole diameter: t r (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
S�nl'
12.Well construction method: 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
_'OR 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:
i
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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