GW1-2021-03196_Well Construction - GW1_20210625

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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14.WATER ZONES
"';Il Contractor N(am(e� /� FROM TO DESCRIPTION
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NC Well Contractor Certification Number 15 OUTER CASING for malti-cased wells OR LINER if a llcable
/� „_ J)Q }fir 1��/ t FROM TO DIAMETER THICKNESS MATERIAL
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Company Name
.16.INNER CASING OR TUBING eothermal'tlosed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) IL It. in.
3.Well Use(check well use): ft ft 1O'
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public tt 30•ft I•in.. •dl0 s�ji V
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
N�o Water Supply Well: ft. fL
Monitoring ❑Recovery ft. ft.
Injection Well:
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❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a 'lieable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage /a►• ft-
t D• rt. Ir P—a F 4.11t
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer 20 DRILLING LOG:attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO ' DESCRIPTION color hardness soilfrock in size eta
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4.Date Well(s)Completed: 1Y—���' Well ID# J4 f��d y y 151 fL '�� � ft.
Sa ft. fL.Well Location: /�
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Facility/Owner Name Facility ID#(if applicable) fL ft rn
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Physical Address,City,and Zip tt ft ' 20
(� :21 REMARKS
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County Parcel Identification No.(PIN) W,3,7On� ��"
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
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6.Is(are)the well(s): lBPermanent or ❑Temporary Signature o rtifieil­Well 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 *<o 15A NCAC 01C.0100 or I5A NCAC 01C'.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#11 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: �t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3y , (fo Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3®200'and 2@100)
Q 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ` 00 Information Processing Unit,1611 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
24b.For Injection Wells: Copy to DWR,'Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ®N 1 rC— 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
_^JR 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:
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13b.Disinfection type: Amount:
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018