GW1-2021-03457_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
5 6 Poo IQ, p 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
a 3a11 / -- JUN X 2021 it. 6 it. w►
NC Well Contractor Certification Number OUTER CASING for multi-cased wells OR LINER a lfcable
raqPOT. ItJd� C�(lf ariz^,atlon pc'�S^fig FROM TO DIAMETER THICKNESS MATERIAL
�i'o_ O ft. t. in. V V
Company Name 16.INNER CASING OR TUBIN (geothermal elosed400
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable evil wnshwction permits(i.e.UIC,Cotatr)•,State,Variance,etc.) ft. ft In
3.Well Use(check well use): tt. it in.
Water Supply Well: 17:SCREEN. ..
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_;Agricultural Municipal/Public ft. ft, in.
_ Geothermal(Heating/Cooling Supply) OResidcntial Water Supply(single) ft. ft. in
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d n• 'L� rr 11 Ird tJ
Monitoring ORecovery ft. %
Infection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK ft llcable
Aquifer Storage and Recovery .Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology OSubsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG tattach iddidonals'heetsifnecessa
Geothermal (Heating/Cooling Return) Other(explain trader#21 Remarks) I FROM TO DESCRIPTION color,hardnM soiVrock type,Wolin d etc
O J oil
4.Date Well(s)Completed: a Well M# M t d o ft. I /,f�!t -
e_.Weu T e �t9Ert: too 8. /O O ft. p p 1 L ro(i L
/ ' b JN
1 ft. i ft
���c� A {1, u�h l I 1
Facility/Owner Name I Facility IDtt of aoolicablel
ft. ft.
a141 T6im,, (Nat J ft. ft.
11 Address.City,and Zip 03 b/
21.REMARKS
County Parcel Identification No.(PW
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifivell field,one tattlong is sufficient) 22.Certification:
N W S,
6.Is(are)the well(s)OPermanent or Temporary Signa f Certified well Contra for Date
By signing this form,7 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consintcaon Standards and that a
tr,hi.;.. .e. .:,it m 11—. i.i.,..,.,i.r„,,.,d copy of1his record has been provided to the well owner.
repair under fill remarks section or an 11m 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
_ _ _ ('!nni!!!r?inn R'Cfari� „!!i n!av n!�:rr nun!'!!rrimti!nt!ni nn,.rs ii[rnresa!y
{.1/L:.ii u4iavu,vw) . ..... . ..,uv..uv,.. ......ww a v-.""-................. ........
filled' I SUBMITTAL INSTRUCTIONS
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wnsttucirvn to the luliuwmg:
10.Static water level below top of casing: f 0 (ft.) Division of Water Resources,Information Processing Unit,
(wwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,!Underground Injection Control Program,
a'•!iR«!1 T!!R CETTLTi !i
13a.Yield(gpm) Method of test: W 24c.For Water Supply&.Iniecttion Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction'to the county health department of the county
LfLwhere constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016