GW1-2021-01874_Well Construction - GW1_20210503

1'1111\:1'VI.111
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ' �l
I� 14.WATER ZONES
Well Contractor Name •^O^ FROM TO DESCRIPTION
6 ft. it. v
2
��5t13; 1JiZ11 ft. ft.
NCwell ,nntractor CertificationNumber iaOi�PrQ
15.OUTER.CASING for multi-cased wells OR t rvER if iicable
FROM TO D[AhiETER TMCKNESS MATE
RRIAL
ft. ft. In. a is t 6 4 1 V!h 1�-e
Company Name
r '� A J Q 16.INNER CASING OR TUBING G eothermaI dosed400
2.Well Construction Permit#: - ` FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
AaoriCultllral E #MI�niCipuilPnbliC it, ft. in.
Geothermal aieating/Cooling Supply) R61tesidential Water Supply(single) ft. ft. in.
Iudustrial/Commercial Residential Water Supply(shared)
llt.GROUT
Im ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Weil: doft'
Monitoring ORecovery
Injection Well:
ft. ft.
Aquifer Recharge OGmundwater Remediation
19.'SAND/GRAVEL PACK a lleable
Aquifer Storage and Recovery Salinity Barrier FROM TO RiATER[AL ErirLACEI!C*^ *sETHeD
Aquifer Test 0Stormwater Drainage fi• ft.
`Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets If necessary)
Geothermal(Heatin Cooling Return) r30ther(explain under#21 Remarks FROM I TO DESCRIPTION color,hardness.solitrock n sba,ete
O ir. Z ft. -h
4.Date Well(s)Completed: Well ID# 2 ft. da ft. A
5a._Well Location: QD ft. v ft 4.rduj h IrOGL
n.
Facility/Owner Name r y. Facility ID#(if appli�cable)cQ ft• n•
V�I IJ•C J� h q yh Ira �JO�, .R.� J 1 1 ft. ft.
Physical Addres,City,and Zip r� ft. ft.
S 3 3(1 21.REMARKS
arty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
afA�- 7 7,7
6.Is(are)the wells) ermanent or TemporaKNo
Signa 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 with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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#11 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Ciosed-Loop Geothermal Wells having the same You may use the bark of this page to provide additional well site details or well
construction,only 1 GW-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
filled' O O SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd perent(example-3Q200'and 2@100� construction to the following:
10.Static water level below top of casing: /0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
l, above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: �1A.I,, 1 construction to the following:
(i.e.auger,rotary,cable,direct pusb,etc.) ��r
Division of Water Resources,'Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ` 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 26 Method of test: 6W 24c.For Water SunDiv&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: 2 r D completion of well construction to the county health department of the county
=9where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016