GW1-2021-03189_Well Construction - GW1_20210625

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
` 0LP%J 5m,441 14.WATER ZONES
well Contractor Name[ FROM TO DESCRIPTION
7�.' 3_1
't IL ft. I
NC Well Contractor Certification Number 15:OUTER CASING(for malti-cased wells ORLINER d a livable
Gam./e r l r, / (�.A FROM TO DIAMETER TffiCKNESs MATERLIL
01 w 1�� rL M in. I �u
Company Name
16.INNER CASING OR TUBING eo'therms l dosed-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. I in.
3.Well Use(check well use): ft. ft. in.
17.5CREEN ,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 'IL TL �' in.
dD 30 � !9•&tO SGJ'i Yv hvL
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(sbared) IS GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
No,qAVater Supply Well: fL ft.
ElMonitoring ❑Recovery fL IL
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL PACK f applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage t It' 30,fL P a Grew
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20:DRILLING LOG attach additional sheets Knecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM u iD To DESCRIPTION color,hardness soiVrock in size etc.
0 � ft. ,�t ft. G, _
a.Date Well(s)Completed: '10-2-1 we # l} BI B I^ 1,5't fL 30'
Sa.Well Location: tI ft. fL Q..
WS. AY�� rt. ft. � aa.
Facility/Owner Name Facility ID#(if applicable) It. fL r
11q5 Na+loQ G�at��'oP TLU. sg Il�b ur y. ,�/ ft.
Physical Address,City,and Zip ��jj IL fL Ii�3GIl2"a(1fln ProceSS11".
n f9 wain '7 7 0 001 6weepe I 21.REMARKS UVVIN
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iattlong is sufficient) 22.Certification:
•7J. &WO a.7 N —S'o• S93 83&0 W
6.ls(are)the well(s): ermanent or ❑Temporary Signature o rtified 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 ILNo 15A NCAC 02C.0100 or 15A 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
9.Total well depth below land surface: 3d • (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2@100)
1 q r (fL) 24a. For All Wells: Original form W to Division of Water Resources (DR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use
11.Borehole diameter: & ,r (in.) 24b.For Injection Wells:Copy 11tor DWI"Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: f d ri I/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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018