GW1-2021-03384_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
`14i<WATER`ZONES,
FROM TO DESCRIPTION
Well Contractor Name o r ry R
W 36'�A 2-r+o It ft U 1 p,r-^"-
NC Well
Contractor Certification Number 15-OUTER CASING`for mnl" w"eDa OR:I INER r, ._. 111 <;
D'T rC1n� FROM I To DIAMETER . THICKNESS MATERIAL
Co y Name //��I I 3 ft is t 0
2.Well Construction Permit#:V v �t/`I LI/"I(i r/�(/W FROM
INNER GASING.OR:TUBIAIM .`ttiermil;tlaecd .
FROM TO DLIM6TFdt THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft 1n.
3.Well Use(check well use): ft. it. in.
'17.SCREEN .
Water Supply Well: FROM TO D14MEfER SLOT SIZE THICKNESS I MATERIAL
Agricultural [3Municipal/Public 0 & & in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) tt ;n,
Industrial/Commercial Dj Residential Water Supply(shared)
18."GROUT .
Irrigation FROM TO MATERIAL ME
I EMPLACENT METHOD&AMOUNT
Non-Water Supply Well: ft10
t1 Q
M Donitoring Recovery ft. IL
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation s,.
19:SANb/GRAVELPACK da 'linable - _ :e
Aquifer Storage and Recovery [)Salinity Barrier FROM TO MATexrer EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage &
Experimental Technology OSubsidence Control ft. &
Geothermal(Closed Loop) Tracer 20.DRILLING`LDG attach additionil iheets'if aece"ik
Geothermal Heating/Cooling Return Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soitfrecg type,gramsae,eta
ft '79 ft
4.Date Well(s)Completed: 54 216Z Well ID# 2Q ft 6 & 5 a yr
Sa.Well Location:
G fL G6S" fiL ran
Ld yrga✓l S f-[b, ft it. JUN
Facility nerName Facility ID#(ifapplicable) IL ft Un)
2 ,• �� sing
V3 /jew R(giel r.hurc� �1I ft '� �'' VIdR Seciion
�Physical Address,City,and Zip & &
21:'REMAItKS ..
County Parcel Identification No.(PIN) 2 R- e Q
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification'
N W
6.Is(are)the well(s)M(Permanent or E3Temporary ignature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or EdNo with 15A NCAC 01C.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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled:
/r^�
SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface:_- 606— (ft) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-/3/a@200'and 2@100') construction to the following:
10.Static water level below top of casing: `1 U (ft) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" -
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
r,� above,also submit one copy of this'form within 30 days of completion of well
Q
12.Well construction method: construction to the following-
(i.e.(i.e.auger,rotary,cable,direct push,etc.) g'
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I
13s.Yield(gpm) Method of test: 24c.For Water Supply&Iniection Fells: In addition to sending the form to
)� the dress(es) above, also submit Ione copy of this form within 30 days of
type:13b.Disinfection e:�( Amount: completion of well construction to 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