GW1-2021-05643_Well Construction - GW1_20210723

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:�
C, 11---n J rj G b a " T 14.WATER'ZONES
FROM TO I DESCRIPTION
Well Contractor Name
AVW q ft O ft.
W
NC Well Contractor Certification Number `� Jr' .:OUTER CASING'for multi cased wells OR2sINER df' ble
Y �B�gCn� FROM TO D TH[CIQVFSS MATERIAL
L0 • tr' 0 ft �b ft is f
�,IV� 011
lj.Q f/
CC i r
Company am�e `1��+ i� 8�
,�G 16.INNER CASING OR-TUBING thei mal desedaob
2.Well Construction Permit#: a 0! FROM TO I DIAMETER I TWCXN SS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) R it. in.
3.Well Use(check well use): it. ft. in.
Water Supply Well: 17.SCREEN
FROM TO`- DIAMETER SLOT SIZE Tinclams MATERIAL
Agricultural [3MunicipaUPublic 0 ft, in.
Geothermal(Heating/Cooling Supply) _, esidential Water Supply(single) it. ft. in
Indush ial/Commercial Residential Water Supply(shared)
,18.GROUT
Irrigation FROM TO MA EMPLACEMENT OD&AMOUNT
Non-Water Supply Well: ft. ft �U O /`�
_ Monitoring Recovery it. it.
Injection Well:
It. ft.
Aquifer Recharge [3Groundwater Remediation
19.SAND/GRAVEL PACK if al 'licible r
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E]Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control & it.
Geothermal(Closed Loop) Tracer ;'20.DRILLINGLDG attach additional iiheets if:neceasa
Geothermal Heatin Conlin Return FROM TO DESCRIPTION color,hardness,sail/rock sim etc.) l
( €,/ g Other(e lain under#21 Remarks)
v` ft, ft. p Q t
4.Date Well(s)Completed: 7 I Well ID# ft. (� ft. C (p t r
Sa.Well Location: �l e11, Co /C)ft. �U ft 71
SGtr1
Rf k 1I ft ,531ft.
Facili'ty/Owner Name Facility IID�#(if applicable) it. ft.
1 `
b W a�`ld„✓ �� Y W ft. it.
Physical Address,City,and Zip ft. fL
21.REMARKS..:,; ..
County Parcel Identification No.(PiN) L5 6,6 er t� J �
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification
N W �.� ] ^ n
6.Is(sre)the well
s) Permanent or Temporary Signature of Certified Well Contraaor Date ( a(
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 No with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Mell Construction Standards and that a
Iflhis 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:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ��� (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(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,
lfwater level is above casing,use I+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: V f (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Q(d4LiP-4 above,also submit one copy of this form within 30 days of completion of well
:
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
' / 1
13a.Yield(gpm) Method of test: Ale L,V 24c.For Water Sunviv&Iniection I Wells: In addition to sending the form to
the addresses) above, also submit one copy'of this form within 30 days of
13b.Disinfection type: Amount: I 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