GW1-2021-03537_Well Construction - GW1_20210607

r i rru r ur tr r
WELL.CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
-4�ASON P00 LE 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ZZ��H ft. p ft. ! U
ft. ft.
NC Well
Contractor Certification Number 1 /► 15.•OUTER CASING for multi-cased wells OR LINER a llceble
\7M� Q��y W IrlAi I PI)11 m 1P co 'Z7tOM TO DIAMETER i I VVC1
THICKNESSft. ft. In.
Company Name
C/( 202. 1
O 2. 1 16.iNNERfiASING OR TI7BIAM eothermal cl THICKNESS
2.well Construction Permit#: J�•If L FROM TO DIAMETER TffiCKNESS 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. is
17.
Water Supply Well: FROME TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipalftblic ft. ft. in.:
Geothermal(Heating/Cooling Supply) ffKlidential Water Supply(single) ft. fL
Industrial/Commercial Residential Water Supply(shared)
18:.GROUT
lrri ation FROM I TO MATERIAL EMPLACEMENT METHOD k AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring Recovery ft. ft.
Injection Well: ft. ft
Aquifer Recharge [3Groumdwater Remediation
19:SAND/GRAVEL PACK(If applicabie
Aquifer Storage and Recovery [3Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft ft
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG fattachaddittorkalsheets Ifnecessary)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks Ffftt.
TO DESCRH'770N color,hardn soiUrock in size,etc
54.Date Wells)Completed: Well ID#Jaw
5a.Well Location: rt.
Facility/Owner Name Facility ID#(if applicable)
ft. ft. s
?, Ito Lb�1�A�-'0 RO 1.bT 2� N�IS� R14�'R. ft ft
Physical Address,City,and Zip ft. ft
►^V C 21.REMARKS' !' rCCDs
�n{{.•rr u 52CItvn
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tattlong is sufficient) 22.Certl ation•
N w
6.Is(are)the well(s) . Permanent or OTemporary Signature of Certified Il Contractor 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: OYes or G? To with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fell 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 1 GW-1 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: 14 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 01617 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 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,1Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 Method of test: %tw 24c.For Water Supply&Iniection Webs: 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
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources