GW1-2021-05481_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1 Well Contractor Information:
Rol n It ��-Fq ft)/ �S�..J! 14:WATERZONES
Well Contractor Name FROM TO DESCRIPTION
it. (7 a ft. 1 ,0
NC Well Contractor Certification Number •'��^
3 Cta>fldn ipro��e5in�Uni 15.OUTER
CASING(for
mu wells)
TOR,LINER ifa licable0 ii
M To DMETEROTHICKNESS MATE RIALG�rG Po a/
ft. 1 -50 ft. in. Ir fj�'S 4 I V
Company Na e
16.INNER CASING OR TUBING(geothermal,dosed-loop)
2.Well Construction Permit#: W Z v FROM TO DIAMETER THICKNESS MATERIAL
List all applicable,vell construction permits(i.e.UIC,County,State, Variance.etc.) 0 ft. !,pa ft. in. PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER: SLOT SIZE THICKNESS MATERIAL
:!Agricultural l unicipal/Public
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. is
__ IndustriaUCommercial DResidential Water Supply(shared) 18.GROUT
lrri ation FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. Z p ft.
Monitoring Recovery
Injection Well:
_:Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL-PACK.if a livable -- •'
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology Subsidence Control
i
Geothermal(Closed Loop) []Tracer 20 DRILLING LOGe'attach additional sheets if necessary)
Geothermal(Heating/Cooling Return Other(explain under#21 Remarks FROM To DESCRIPTION rotor hardnes soiUrock in si etc
- ft. 2, ft.
4.Date Well(s)Completed: 1D I I Well ID# Z ft. 7 V ft. 44'L
5a.Well Location: tt. 'f d O
M� P✓N�`C.I �Iw I I It� S ft. ft.
Facility/Owner Name C Facility ID#(if applicable ft. ft.
r
ft. ft.
Physical Address,City,and Zip �j�/ / , S
V✓ u Pt 61� 9 a O S 1 1p OS 3 1 21.REMARKS
County Parcel Identification No.(PIN) 1 h / -e _ b s V
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Ce ]cation
• d
N W
6.Is(are)the well(s) Permanent or Temporary Signa a of Certified Well or Date
By s gning this form,I hereby certify that the we11(s was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or gNo with ISA NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis 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.
dried: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: d (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: Z Division of Water Resources,Information Processing Unit,
If water 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
above, also submit one copy of this form Within 30 days of completion of well
✓
12.Well construction method: 1 o-fa r� 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
13a.Yield(gpm) Method of test: 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 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