GW1-2021-03540_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1Well Contractor)Information:
{ )US�CIn l.-e.�c�nin�nf 14.WATER'ZONES
FROM TO I DESCRIPTION
Well Connector Name
W36t�A �0 �
ILq6 R NC Well Contractor Certification Number L�
15.OUTER CASING for malty ased wells ORL—Eak'di"' M
FROM I TO/ DU1METFdt THICKNESS /MATERIAL
Co any Name I-I fL l7 ft- G is i /Liff
16.INNER CASING OR TUBING -thermal dosed lod
2.Well Construction Permit#:G W^©��W' FROM To DIAMLTER — CKNEss MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) % ff 1n
3.Well Use(check well use): ft. ft in,
Water Supply Well: 17.SCREEN-.-...'.
FROM TO DIAMETER : SLOT SIZE THICKNESS MATERIAL
Agricultural [3MunicipaVPublic U ft. ft. in.
Geothermal(Heating/Cooling Supply) bCsidential Water Supply(single) ft. ft.
Industrial/Commercial DResidential Water Supply(shared)
4&GROUT.
Irrigation FROM TO MATEPJAL EMPLACEWIENVT METHOD&AMOUNT
Non-Water Supply Well: Q ft. ZQ ft. a �
Monitoring j Recovery fL &
Injection Well:
Aquifer Recharge Groundwater Remediation R
19.:SAND/GRAVEL PACK da 'Geable
_ Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft. ft
Experimental Technology Subsidence Control & ft.
Geothermal(Closed Loop) Tracer 20.-DRILLIlVG',LOG attach additionil''sheets if necess
Geothermal Heatin g/ g Return) FROM TO DESCRIPTION color hardness,soillreck size,etc.
) _,Other(explain under#21 Remarks) O ft. 3-3 ft. O
4.Date Well(s)Completed: 6 3 W44 Well ID# ft
5a.Well Location: ft 3l ft s'�:
ayeyq NQf./�Q� fr. ft. bh
Facility/Owner Name Facility ID#(if applicable) & ft.179 7 2
a ,AL C A61/iN ft rr nit
Physical Address,City,and Zip a & ft. 171,
� r-c¢c gun
Wh t" P21L REMARKS:,:
County Parcel Identification No.(PIN) tk
IW
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N �y6�
6.Is(are)the well(s)dpermanent or OTemporary Signature ofCafieTWell Contractor f5ate
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: []Yes or ENO 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-I 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 surfacer (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+/ 1617 Mail Service Center,Raleigh,NC 27699-1617
ll.Borehole diameter: l7 (in,)
24b.For Infection Wells: In addition to sending the form to the address in 24a
.Well construction method: &l7 f
�I--a above,also submit one copy of this form within 30 days of completion of well
f
(i.e.auger,rotary,cable,direct to the following:
ect push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: II, 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: V l� 24c.For Water Supply&Injection Wells:: In addition to sending the form to
n the address(es) above, also submit!one copy of this form within 30 days of
13b.Disinfection type: Amount: U 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 Revised 2-22-2016