GW1-2021-03313_Well Construction - GW1_20210603

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contract'
I formation:
tq�V ackv 14..WATER ZONES L.
Well Contractor Name FROM TO DESCRIPTION
tr. ft.
d- 13 R ft.
NC Well Contractor Certification Number
///��� ////// _ .15..OUTER.CASIN ,( r multi,eased wells UR''LINER:If a�- llratble -
I� VI �'' 1'71� �v ,, / U G FROM TO DIAMETER Tt1ICKNnESS MAfT-�FEE
✓�/ T- l 1 ft. ft- �1 n•. O D 9 02 J PVC,
Company Name r a�
16:INNER EASING OR TUBING cothermal`Elosed-luo
2.Well Construction Permit# �-( / FROM ro DIAMETER THICKNFSS I MATFRIAL
List all applicable well canstr ildion permits(i.e.UIC,Coi ny,State,Variance,etc.) I't• ft. lu.
3.Well Use(check well use): n' ft. 1°'
Water Supply Well: 17.SCREEN.* .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public 11, ft. In.
Geothermal(Heating/Cooling Supply) besidential Water Supply(single) ft. ft. j In.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 10 ft. ft. b Q 5
Monitoring Recovery ft. - fL
Injection Well:
ft. ff.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK P a 1[cablc'
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology [3Subsidence Control ft. ft.
Geothermal(Closed Loop) ElTracer 26.DRILLING LOG.attach additional sheets:It.necessa
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness sol0rock type,gmin size etc.
ft.
/ u. Q
4.Date Well(s)Completed: / ( Well ID# U L
5a.Well Location:
Facility/Owner Name 1 1 Facility IDk(if applicable) R' R
�1 fez g e dI )qpp )e 0 r. ft. ft. 0
Physical Ad7s,City, nd Zip ft. D' vitilt
as f 21.REMARKS 0
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification•
�; 3333ro r81� -'7qW� W
6.Is(are)the well(s) rmanent or OTemporary Signature of Certified Well Cannactoi Date
By signing dris form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consn•action Standards and that a
If Mis is a repair,fill out larow rt well consiniction information and explain Ike nature of the cop),of/his record has been provided to the imll owner.
repair under 1121 remarks section at-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 site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: / SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: L [ (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Ior ninhiple wells lirt all depths ifdderent(example-3@200'anJd�2@100) construction to the following:
10.Static water level below top of casing: "t (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,rise"+^ 1617.Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy ofYthis form within 30 days of completion of well
12.Well construction method: r� O` ✓ construction to the following:
(le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) b Method of test: r 24c.For Water Supply&Inielction Wells: In addition to sending the form to
t / the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: I a completion of well construction to the county health department of the county
where constructed.
i
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016