GW1-2021-01008_Well Construction - GW1_20210419

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
1 J14-coh
14:WATER ZONES ,
Well Contractor Name FROM t. TO DESCRIPTION
f '
� it. ft.ft. l j
NC Well Contractor Cert^i7fifcatio�n�Number is.OUTER CASING far multi cased wells OR LINER a lica6le
[ J'I'O I WEt I L(/s FROM TO DIAMETER TRICI m MATERIAL. /
ft. i ft. Ia )8 4(i/
Company are 16.INNER CASING OR?UBING eotbermal closed-i6
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constnrction permits f.e.UIC,Cmunty State,Variance,eta) ft. % in.
3.Well Use(check well use): 3 2 3 ,`i ft rt in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTS17E THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft it in.
❑Geothermal(Heating/Cooling Supply) 13f6sidential Water Supply(single) ft. %
Olndusttial/Commercial ❑Residential Water Supply(shared) 1&GROUT
_ ❑Im ation O Wells>100,000 GPD FROM TOO MATERIAL EMPLACEMENT aIE OD&AMOUNT
Non-Water Supply Well: ft d 0 m Hole
e hU ' O0f
❑Monitoring ❑Recovery M ft
Injection Well:
ft ft.
[]Aquifer Recharge ❑Groundwater Remediation
.19.SANDiGRAVEL:PACK fifapplicable),
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL: EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRUJUNG LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain trader#21 Remarks) FROM T O DESCRIPTION eobr,bards somrock run slug etc
ft ft —/ Sor` I
94.Date Well(s)Completed: �� Well ID# IL ft- C 4 l
Sya�.Well Location,: t40 ft C15- ft, �✓ah n �� � �"
r f ar i, 1.1 of ft. ft 9
Facility/Owner Name Facility ID#(if applicable) ft ft s i U iZl�
JD W- (--veK S4, ft
Physical Address,City,and Zip ft ft
rq 11 F':/, 2LREMARKS
County Parcel Identification No.(PIN) P`� Gr t"x c
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lattlong is sufficient) 22.Certification: f
N W
6.Is(are)the well(s): Efg..anent or ❑Temporary Signature of Certified Well Confractor Date
�� By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 0No 1 SA NCAC 02C.0I00 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe 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 construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3�L/ (ft)
For multiple wells list all depths ifdi(ferent(example-3Q200'and 2Qa 1001 Submit this GW-1 within 30 days of well completion per the following:
24a. For AD Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: E� (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
�p 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (�•) Program,1636 MSC,Raleigh,NC 27699-1636
12 WeD constriction method: AG r"� 24c.For Water Supply and Qpen-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental heal department of the county where installed
E
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Co to D
Permit Program,1611 MSC,Raleigh,NC 27699-1611 Copy CCPCUA
13a.Yield(gpm) � Method of test: 0�� l
13b.Disinfection type: Fr Amount:
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 S