HomeMy WebLinkAboutGW1-2021-02261_Well Construction - GW1_20210514 � iirurunn
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Infor+(m�ation:�(�
14.WATER ZONES
Well Contractor Name y r FROM TO DESCRIPTION
(SO fL ft. ��,o
NC Well Contractor Certification
Number 11.OUTER CASING for multi-ea"sed:"eus OR 1 INER if a lieabie
FROM R TO fL DIAMETER in. T�CKNES5 MATERIAL
Company Name
b 5b
16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: 11 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,CowNy,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
Agricultural �1�Iunicipal/Rtblic it. ft. in•
Geothermal(Heating/Cooling Supply) [)Residential Water Supply(single) fL 111. in,.
Industrial/Commercial residential Water Supply(shared) 18.GROUT
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUrfr
Non-Water Supply Well: b ft. fL .S
Monitoring DRecovery
Injection Weil: fL ft
Aquifer Recharge OGmundwater Remediation
19;:SAND/GRAVEL PACK ifs Iicable
rn Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT R!ETHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attar?additional sbeets if necessa
Geothermal(Heatin Coolin Return Other(explain under#21 Remarks FROAt To DESCRiPTiON col hardn soiUrock rain sfz etc
10 ft. r /LQ ft'
4.Date Well(s)Completed: Well ID# �/ ft ft.
5a Wen r ccat!c.. �f�ft. .50 ft� �,y`
� t��-�- nn,, ,` r i!� r � r
-i l--W.m /l m f 1 ft. ft.
Facility/Owner Name, `1 Facility ID#(if applicable) 0 ft. O tt. C
140 PaWl, M10Mt NC it fL
Physical Address,City.and Zip
ft. ft.
e�WA A 1 21.REMARKS
County IV Parcel Identification No.(PIN)
r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lattlong is sufficient) 22.Cerdfieationa a
N W
6.Is(are)the well(s) Permanent or Temporary Signature of Ce fied Well Contractor Date
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 (o with 15A NCAC 02C.0100 or 15A NCAC 02C.0260 Well Construction Standards and that a
tin n„r 6.n„m-n,.n. nd<tit t.,rao-ft-nnt,o copy 9f this record has been provided to the well owner.
repair under VI remarks section or on the bank 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
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filed' SUBMITTAL INSTRUCTIONS
t1 'l nttl-Mf A~n hnln!!!InnA en Notin• itt 1 ..• .- ... .:. ,. .- , .• .. -
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cuustrucGun iu UIC lulluwwg:
10.Static water level below top of casing: 1 0 (ft.) Division of Water Resources,Information Processing Unit,
If ivater level is above casing,use"+" t- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1n.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
CW above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: ����ffff construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
13a.Yield(gpm) Method of test: D N✓ 24c.For Water Su Duly&Inlection Wells: In addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: k YIN Amount:-1bs 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