GW1-2021-05833_Well Construction - GW1_20210709

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WELL CONSTRUCTION RECORD (GW-1) 9 2OZ1
cessing Unit
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1.Well Contractor nformation: I _ 6SClOn- s
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FROM O ESCRIPTION
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Well Contra o;Name
va in( it
NC Well Contractors Certification Number 5..-OUTERCASINGj(for dial'_aisedywells)OL RtLINERI(ifiapplicabte)
kl n.071 GV'�i6/ L/ r /� �'l q ROM O IAMETER [THICKNESS NATERIAL
Company Name ft ft] in -a &
2.Well Construction Permit M Zto Q I a0001 'ys' 61INNER>CASING OR T. ,�UBIN,G})geottiermal ctosedtloop)mommon:a� ;
List all applicable well contraction permits(i.e.UIC,County,State,Variance,etc.) 'ROM �O DIAMETER [THICKNESS MATERIAL
ft ft in
3. Well Use(check well use): ft ft in
ater Supply Well: 7 SCREEN *'
ROM _ O PIAMETER LOT SIZE HICKNESS NATERIAL
Agricultural ❑ Muncipal/Public
ftl ft in
(] Geothermal(Heating/Cooling Supply) ❑ Residential Water Supply(Single) ft ft in
Industrial/Commercial ❑ Residential Water Supply(Shared)
11 Irrigation
6GROUTk _
ROM TO MATERIAL MPLACME T METHOD&AMOUNT
Non-Water supply Well: ft ft A n� / C
❑Monitoring ❑ Recovery ft ft
Injection Well: ft ft
❑ .ANDIGAVELPAC.S A(if appcable)
Aquifer Recharge ❑ Groundwater Remediation ROM O MATERIAL JEMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑ Salinity Barrier ft ft
❑Aquifer Test ElStormwater Drainage ft ft
❑ Experimental Technology ❑ Subsidence Control 0.DRILLINGILOG attach additiona 1l sheets if r ebessary) WNW
❑ Geothermal(closed Loop) ❑ Tracer �� (� -- i
ROM O DESCRIPTION(color,hardness,soil/rock type,grain,size,etc.)
❑ Geothermal(Heating/Cooling Return)❑ Other(explain under#21 remarks) ft ft
ft ft — SQ
4.Date Well Compteted: l Well ID# ft
5a.Well lo16
cation: ft ft
/C.,,e,G1 d^4t' a"ton ft ft
Facility ner Name acility ID#(if applicable) ft ft
ft ft
P sical Address, ity and Zip 1 ,'REMARKSAn `F
v1
County V Parcel identification#(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal 22.CE (CATION: ^�
degrees: 6—
N W Signa of Certified Well Con for Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with 15 A NCAC
6. Is(are)the well(s): 0Permanent or ❑Temporary 02C.0100 or 15 A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been
provided to the well owner.
7. Is this a repair to an existing well: ❑Yes or 0 o 23.Site diagram or additional well details:
If this is a repair,fill out known well construction informtion and explain the nature of You may use the back of this page to provide additional well site details or well
the repair under#21 remarks section or on the back of this form. abandonment details.You may also attach additional pages if necessary.
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the SUBMITTAL INSTRUCTIONS
same construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of
wells drilled: 24a.For All Wells:Submit this form within 30 days of completion of well construction
to the following:
9.Total well depth below land surface: (ft.) Division of Water Resources,Information Processing Unit,1617
For multiple wells list all depths if different(example-3@200'and 2@100) Mail Service Center,Raleigh,NC 27699-1617
10.Static water level below top of casing: 3O (ft.) 24b.For Injection Wells:In addition to sending the form to the address in 24a above,
If water level is above casing use"+" / also submit one copy of this form within 30jdays of completion of well construction to the
11. Borehole diameter: (in.) following: !
Division of Water Resources,Underground Injection Control
12.Well construction method: / Program,1636 Mail Service'Center,Raleigh,NC 27699-1636
(i.e.auger,rotary,cable,direct push,etc.)
24c.For Water Supply&Injection Wells:In addition to sending the form to the
FOR WATER SUPPLY WELLS ONLY address(es)above,also submit one copy of this form within 30 days of completion of well
13a.Yield(gpm): Method of Test: A,',-l construction to the county health department of the county where constructed.
13b.Disinfection Type: /r Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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