GW1-2021-02324_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information.
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FROM TO DFSCRWnON
11 Contractor Name ft IL
4
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NC Well Contractor Certification Number , &OUTER CASING fur multi-a"sed wells:OR:l4NER.tfsii"'
FROM TO DiAMF.7'a
THCKNE
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Co y Name 41 f ft- ( 641 n
-� < `,46:INNER CASING�01 TUBING, "iliermiii;di
2.Well Construction Permit#:V62�✓y FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. 1 L
3.Well Use(check well use): fr' ft. in.
Water Supply Well:
FROM TO J DIAMETERS Y.SLOTSIZE; TMCKNM I MATERIAL 4
Agricultural 13MunicipaUPublic 0 ft. ft. io
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) ft. ft. in.
hidushial/Commercial DResidential Water Supply(shared)
18.'GROIJI x
_ __ _.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: oft Zo % v
Monitoring Recovery ft. fL
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19:SANDIGRAVEL'PACK-
Aquifer Storage and Recovery 1 Salinity Barrier FROM TO MATEERIAL I EMPLACEMENT METHOD ,-
Aquifer Test 13Stormwater Drainage & &
Experimental Technology EJ Subsidence Control & fL
Geothermal(Closed Loop) 13Tracer 7 20.-DRILLING LOG attach addrtidu0slieets4:nec
Geothermal(Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRRMON color,hardness,soiltrock sae,etc}
60 a
4.Date Well(s)Completed: s 3 Well ID# 66
ft. fc
p �
5a.Well� (
Location: 1 p fL fL 5 Q /l 1 Q, r �
C-i/6k /- ch i� 0 es ft ft
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Facility/ r Name 'T Facility ID#(if applicable) ft ft r' 02
219a NG U wv crvj000f ,t. ft. \311;c
Physical Address,City,and Zip ft. ft.
G/ (ft 1('le
Canty Parcel Identification No.(PIN) a Q Q.4 V e e
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certificati `
N W
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified 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 dN0 with 15A NCAC 01C.0100 or 15A NCAC 02C.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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
r SUBMITTAL INSTRUCTIONS
9.Tbtal well depth below land surface: 1 (ft 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-33@200 and 1@100') construction to the following:
10.Static water level below top of casing: 7 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: r(r l/ 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 Centr,Raleigh,NC 27699-1636
13s.Yield(gpm) Method of test:�_ 24c.For Water Supply&Injection 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: 7 Amount: z 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