GW1-2021-05675_Well Construction - GW1_20210723

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
e /'1O✓y ,ail COjS .`14.RATERZONES s
Well Contractor Name FROM TO DESCRIPTION
ft OL
NC Well Contractor Certification,/Number \\\'C1 3 UTER•CASING for multVmed;,Was OR`IsINER:
r0 fi WC Jy� rt✓�5�� FROM TO D THICKNESS MATERIAL
fL fL in.
Compaq ame 16 INNER CASING:OR TUBING, >16ermal:d ,k-
2.Well Construction Permit#: • o�� FROM To nrAMETER TffiCKNFSS �I MATERIAi.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft. ft 1O
1�-SCREEN ;;4 ,
Water Supply Well: FROMr TO DIAMErER '.SLOT SIU I THICKNESS MATERIAL
Agricultural [3Municipal/Public 0 & ft. in
Geothermal(Heating/Cooling Supply) residential Water Supply(single)
ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
.1s.GROUT_
_
Irt i ation FROM TO MATERIAL EMPLACEMENTWIMOD&AMOUNT
Non-Water Supply Well: ® ft o ft 49 fr
Monitoring .Recovery fL ft.
Injection Well:
Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL PACK if a `7icable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT MEMOD
Aquifer Test [3Stormwater Drainage fL ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal Closed Loop) Tracer( p) ;20:DRILI,IlVG LOG attach.addrtioniil;eheets if nei:`ess ,<..,.
Geothermal(Heatin Cooling Return) _ Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardnes%wlurxk qrpe,grain site,eta
p ) © 't fL a so,t
4.Date Well(s)Completed: W-a I-gI Well ID# 3 fL � ft. 14
VA
5a.Well Location: Q ft G fL —repro
W AWCPyn QI'll�/ 5 fL tt 4
Facility/Owner Name Fa ''ty ID#(ifapplicable) ft. ft.
1�llJ y l I n ft. ft.
Physical Address,City,and Zip ft. ft.
lnl�kP Z1:REMARxs . : . . _
County Parcel Identification No.(PIN) Q Qr eb d
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification: ['
N W
,
6.Is(are)the well(s) Permanent or Temporary Signature of Certified well C tractor Date
/' By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or [3No with 15A NCAC 01C.0100 or 15A NCAC 01C.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 surface: G
/ (ft) 24a. For All Wells: Submit this form'within 30 days of completion of well
For multiple wells list all depths ifdi�erent(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: a y (ft.) Division of Water Resources,Information Processing Unit,
Ijwaterleve!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
12.Well construction method:
,P Ct7�Xry above,also submit one copy of this form within 30 days of completion of well
i
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPL�Yj 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 �. r� 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