GW1-2021-02331_Well Construction - GW1_20210527

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information::
pa A., 14.WATER ZONES
FROM TO DESCRIMON
Well Contractor Na e C
O ft ft
t
NC Well Contractor Certification Number w1 15.OUTER CASING for tnniti cased weds OR LAVER'if cable
(, y P�le 1 I i1 r . FROM TO D TEIt TEIIC[�1E66 MATERIAL
Company Na (� v O ft cl 2 ft. in. 4 / v g 4/�,
16.INNER CASING.OR TIIBING othermal closed-loo
2.Well Construction Permit#: FROM I To I DIAMETER I TIUCKNFSS I 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 TFIICKNESS MATERIAL
Agricultural []Municipal/Public ft fa In.
Geothermal(Heating/Cooling Supply) DResidwtial Water Supply(single) ft IL
LmdustriaUCommercial Residential Water Supply(shared)
18.GROUT
IIri ation FROM TO MATERIAL EMPLACEMENT MMOD&AMOUNT
Non-Water Supply Well: ft' Z tf ft Ytx
Monitoring Recovery ft. ft
Injection Well:
ft ft
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK>ua livable
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) OTracer 10:'0RII LING LOG attach addidonal sheets If necessary)
Geothermal(Heating/Cooling Return) E30ther FROM TO DESCRIPTION color hardness,soW—k to etc.)lain under#21 Remarks) Q ft. 2 ft. ' d Ofs!
4.Date Well(s)Completed:J - Z O Well ID# Z,
Sa.Well Location: ft aA5
ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
7 r u Kt It J S D rtn 4 7 6 f2- Ir—
Physical Ad ,City,and Zip—I �N
v aS 17 M Y o o (45 76 Z1:REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
,,,. „� �v11 fJrw{;n4ctrtJ lit
(ifwell field,one lat/long is sufficient) rl v
22.Certification:
N W Lr
6.Is(are)the well(s)4Permanent or Temporary Signature of Certified Wed Contactor 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: nYes or fi!(No with 15A NCAC 02C.0100 or/5A 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 1 GW-I is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled' I Z*�-5 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 ifdorerent(example-3@200'and 2@1001 construction to the following:
10.Stack water level below top of casing: 2-O (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
V above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 6 r/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: --/ 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) `/y Method of test: /0 W _ 24c.For Water Supply&Inlecdon 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: 1 'I Amount: 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
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