GW1-2021-03482_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Informatio�jn:
t 14.WATER ZONES
Well Contactor Name FROM TO DESCRIPTION /
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NC Well Contractor Certification Number �� U%111 15.OUTER CASING for multi-cased welts OR LINER if a licable
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U tl ! 'a 1 � `�J'�I I �i..Q�-4ric t��r^��¢.^,.�,oO FROM ft. TO fL D in. TRIICKESS MATERIAL
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Company Name 1J•' ✓ /� (1/
1 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: `) ( FROM To DIAMETER T1ICKINESS 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 SLOT SIZE TRICKINESS MATERIAL
Agricultural DMunicipal/Public 0 ft. ft. in.
J Geothermal(Heating/Cooling Supply) � esidential Water Supply(single) ft in.
_ Industrial/Commercial Residential Water Supply(shared) 18.GROUT
J Irrigation FROM TO MATT UAL EMPLACEMENT N&MOD&AMOUNT
Non-Water Supply Well: ft () ft l e rall
_ Monitoring QRecovery ft. ft
Injection Well:
ft ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
J Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
J Aquifer Test []Stormwater Drainage ft fL
J Experimental Technology Subsidence Control ft. ft.
_;Geothermal(Closed Loop) Tracer ° 20.DRILLING LOG attach additional'sheets if necessary)
Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiVroek in size,etc
. � 1 Well ID# aft ft TOP-5o
4.Date Well(s)Completed• ft 0 fL C_I 0
5a.Well Location: d ft. L'0 It. -$G n
14 p ft 30.S' ft Sat dc
Facility/Owner Name Facility ID#(if applicable) fL ft
4�J,I�0 S Rc, it ft
Physical Address,City,and Zip & ft
i r�yM 21.REMARKS /
County v Parcel Identification No.(PIN) S e e/ i f ✓?t^ 19 r,V e -s e.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
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S_6.Is(are)the well(s)ePermanent or Temporary Signature ofCertified Well Con Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 01�es or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy 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 site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 'J SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: G% 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: t�y (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: in.
(� ) 24b.For Infection Wells: In addition to sending the form to the address in 24a
4O�(f r/ 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,
FOR WATER SUPPLY WELLS ONLY: /� / 1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) Method of test: 1310 w 24c.For Water Supply&Iniection'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 tol the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016