GW1-2021-04412_Well Construction - GW1_20210805

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.WelliContractor Information:
V a ryI Pa 6 14.WATER ZONES
Well Contractor Name FROM TO DES ON
a�7 ft. soft- ,
ft. ft.
NC W(/ell Contractor Certification Number IS.OUTER CASING for mull-cas TERe1IS OR LINER if n Heable
FROM I TOTHICKNESS MATERIAL
Company Name ft P� ft. in. /2 1 ve
_ I6.INNER CASIING OR TUBING eothetmal'elosed-loo
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2.Well Construction Permit#: V 0 foot FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft !7 Jt ft. , in, V
3.Well Use(check well use): ft. [t. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public & in,"
Geothermal(Heating/Cooling Supply) gResidential Water Supply(single) ft. ft.
%dustrial/Commercial DResidential Water Supply(shared)
18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT MUNOD&AMOUNT
Non-Water Supply Well: © ft. O ft. �� r Q
Monitoring DRecovery ft. ft. kJ
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL,PACK(if Appileablo
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft,
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer 720,DRILLING LOG'attach additional sheets If necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnen,soiVrock type,grata size,eta
b ft. z—
4.Date Well(s)Completed: Well ID# 2
5a.Well L cation: v 1t. ft. P1 rock
lisp. d e/a re"14 (7011.
Wl* Or — rOCA
Facility/bwner Name Facility ID#(if applicable) ft. ft.
0 3 Q rs �w I k ft ft.
Physical Addre s,City,and Zip J V O SS O ft, ft.
AI ,6 21.REMARKS
County Parcel Ident [cation No.(PEN) Q I/
e i m r bobf tv 7j fr
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) ' 22.Certification: 'L
N V ®-
6.Is(are)the well(s) . Permanent or Temporary Signatufbf Certified well Contractor Date
f�signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYe, or ff No Ft t + K l X �+ 20>�ifh 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constriction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature o the t�iecord has been provided to the well owner.
repair under#21 remarks section or on the back of this form. information FroCgg81
DW R SeCtiojp.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.
filled' 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 if different(example-3@200'and 2@100') construction to the following:
10
10.Static water level below top of casing: (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 Infection Wells: In addition to sending the form to the address in 24a
AOC above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1r�
(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: l 1636 Mail Service Ceni er,Raleigh,NC 27699-1636
13s.Yield(gpm) Method of test: �I b U) 24c.For Water Supply&Inlectionp 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: 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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