GW1-2021-03191_Well Construction - GW1_20210625

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14i WATER ZONES
ell Contractor Namue(,� ,, AFROM TO DESCRIPTION
fL ft. i
NC Well Contractor Certification Number n 15:OUTER CASING for.multi-cased wells OR LINER da licable
Gas 6a de ♦ I rLt P (� FROM TO DIAMETER THICKNESS MATERIAL
ft.Company Name
16:INNER CASING OR TUBING geothermal closed-looDY
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17:SCREEN
FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL
❑A cultural ❑Munici al/Public t '
gn P -•p ft. �0 ft Z� 1°' p.[9 &to PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fL ft.
❑Monitoring ❑Recovery ft ft.
Injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage $' R• ft- 4
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20:DRII LING LOG attach.additional sheets if.necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness solUrock a ate size etc.)
ft ' ft
4.Date Well(s)Completed: �'I�Z( Well ID# /t 0(d 3-V V s" ft. a ft.
c, Well Location: S^Q it �Q• tt
US. AM ft. ft —
Facility/Owner Name Facility ID#(if applicable) ft ft.
Q5' /11a��btlla( G ,44 P.D. 5-4PS10 .� rt ft-
I, JU
Physical Address,City,and Zip (� ft. ft OC£SSiIt(g Vl{1
2vwa y► f V 7 21:REMARKS.` t I r 11
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:
36. 63'o�y19 N -s19. 3-'zi6 763
6.Is(are)the well(s): BTermanent or ❑Temporary Signature o ertified 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 MIVo ISA NCAC 01C.0100 or ISA 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 I 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: (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if di,(jerent(example-3Q200'and 2Qa 100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use j
6 c r 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: S®IA t•c• 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
rJR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources! Revised 6-6-2018