GW1-2021-02612_Well Construction - GW1_20210620

WELL CONSTRUCTION RECORD(GWAI For Internal Use Only:"
1.Well Contractor Information:
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F7 `zA(1 k r;ckl Q (\\ 14.WATER ZONES
Well Contractor
Name
t ` S�\ FROM TO DESCRIPTION
6 ft, ft
'R
NC Well Contractor Certification Number
I5.OUTER CASING for old-cased wells OR LiNER if applicable)
f_L1�AC); i 1nk, 1 ►/��M FROM TO DIAMETER THICKNESS MATERIAL
Company Name UY` wX. a ` ♦' fL fL m in- i
841
U C t
�� !t()I try O 1G INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: V 6 FROM TO DIAMETER THICKNESS MATERIAL
List all applicahle we//construction permits(i.e.VIC,County.State,Yariance,etc.) fL fL in.
3.Well Use(check well use): fL fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MA
❑Agricultural ❑Municipal/Public fL fL in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL fL is
❑industrial/Commercial El Residential Water Supply(shared) 1&GROUT
OIrrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD d
Non-Water Supply Well: t AA ft. 'L0 fL
❑Monitoring ❑Recovery FL ft.
injection Well: ft fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PAC K ifs livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMET
dAquifer Test ❑Stormwater Drainage fL fL
❑Experimental Technology ❑Subsidence Control ft. fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM fL ft.To DESCRIPTION color,hardness,soil/rock type,grain,
4.Date Well(s)Completed: P) I Well ID# ft. fL
Sa.Well Location: ft. fL
Pal 11 _M'1'r\e, a ft. fL
Facility/OwncrName -�� Facility ID#(ifapplicable) ft. fL
Physical Address,City,and Zip
ft. ft.
Nash
21.REMARKS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one(attlong is sufficient) 22.Certification:
N W ///, - , Z %----
6,Is(are)the well(s): 9we-rmanent or ❑Temporary Si C ' Well Contractor D e
fly sign' this jorm,l hereby ces •that the well(s)was(were)constructed in acci
7.Is this a repair to an existing well: ❑Yes or 11'0 15A N AC 01C'.0100 or 15A NCAC 02C.0200 Well Construction Standards ant
If this is a repair,fill out known well construction information and explain the nature of the of th record has been provided to the well owner.
repair under 921 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 constru
construction,only (GW-1 is needed. indicate TOTAL.NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages it
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the followi
For multiple wells list all depths if d fferent(example-3@)200'aanGnd 1®100')
10.Static water level below top of casing: �7 (ft) 24a. For All Wells: Original form to Division of Water Resoure
If a•aier level is above casing,use" information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter; (in,) 24b. For Infection Wells:Copy to DWR,Underground injection Cc
((,�,,,�� � Program,1636 MSC,Raleigh,NC 27699-1636
12,Well construction method: C411DA-0- 24c.For Water Supply and Open-Loop Geothermal Return Wells:
(i.e.auger,rotary,cable,direct push,etc.) county-environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100 000 GPD: Copy to DWR
13a.Yield(gpm) l�( Permit Program,161 I MSC,Raleigh,NC 276 9-1611
Method of test:
13b.Disinfection type: Amount:
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Rev