GW1-2021-05477_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Info501,
tion: RECEIVED
j
r 4 Jill i O 14.WATER ZONES 1
Well Contractor Npfne
FROM TO DESCRIPTION
ft. 0 fL
Information Processing Urli
DWR Sect'•on ft. ft.
NC Well Contractor Certification Number / 15.OUTER CASING for multi-cased wells OR LINER a lleable
rQ�() ����� ��� 6 PwMp / A(J FROM TO DIAMETER TECH NESs MATERIAL
U I 1 � O CtJSa ft. an.
Company Narrul
L a - p D b a,�a FR INNER CASING'OR TUBINGIAM eothermal cl THICKNESS
2.Well Construction Permit#: 1 FROM TO DIAMETER TIDCKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Yariance,etc.) ft. v
3.Well Use(check well use): ft. ft.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER':, SLOTS12Z THICKNESS MATERIAL
Agricultural Piunicipal/Public ft fL in.
Geothermal(Heating/Cooling Supply) WResiticatial Water Supply(single) ft. I ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
lirl ation FROM TO MATERIAL EMPLACEMEn METHOD&AMOUNT
Non-Water Supply Well: ft R.
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.'DRILLING LOG attach additional heets ifnecessa
FROM TO DESCRWnON color,hardness,soilfrock rain size,eta
Geothermal Hearin Coolin Return) Other(explain under#21 Remarks)
e SOI
4.Date Well(s)Completed: i' Well ID# tt. O tt.
5a.Well Location: ft' 0 R' h ro-&k•
'70it. ft roG
Facility/Owner Name ,II Facility/ID#r(if applicable) ft. ft.
107 Q rY er S n(d 1)) z 4!D&l b h I tjs' ft. ft.
Physical Addres City and Zip ft' ft.
NaS • 33wr r i 21.REMARKS
County Parcel Identification No.(PiM hi Ned to o * 1 In 0(- IND t St
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: o gd .
(ifwell field,one lattlong is sufficient) 22.Cer (cation:
Ot N WZ - —
` 1 P [ 1
i
6.Is(are)the well(s) ermanent or Temporary Signature of Certi red well 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: 3Yes or No with IJA NCAC 01C.0100 or 15A NCAC 02C.0100 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 300 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths 1f dierent(example-3 200'and2®100') construction to the following:
10.Static water level below top of casing: AO (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
i
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: ft construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: (p` 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: U 10 W1 24c.For Water Supply At Infection 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: kf Amount: I completion of well construction to the county health department of the county
where constructed. f
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016