GW1-2021-01918_Well Construction - GW1_20210415

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
LT
D a(e. a �- 14.WATER ZONES
a FROM TO I DESCRIPTION
Well Contractor Name ;>•' •t v ft ft.
APR 5) 2021 ft. ft.
NC Well Contractor Peb
Certification Number //�� 15.OUTER CASING for tnuld-cased wells OR LINER if applicable
ti�J
Dram° �� W-I� � P
n„ i 1� OM TO DIAMETER THICKNESS MATERIAL
,, IiY�� � CCC�,,� a ft. �S 2rt. ia. �g g
Company Name _ V V K
q y/�y 16.INNER CASING OR TUBING eothermal dosedaoo
2.Well Construction Permit#: I Q Od • v FROM TO DIAMETER TMCKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft.
Water Supply Well: FROMRFF, TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. n'
Monitoring ORecovery
Injection Well:
ft. ft.
Aquifer Recharge 00roundwater Remediation
19:SAND/GRAVEL PACK a flcable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) 00ther(explain under#21 Remarks FROM TO DESCRIPTION color,hardn soil/rock type,grain Am,etc
G ft. Z ft. t-ple St7/
4.Date Well(s)Completed: . as-a Well ID# Z ft. 00 ft al C
5a.Well Location: �Q ft. ZQV it. Iq ro(;k
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
7 b-7J ft. ft.
Physical Address,City,and Zip
/ .4 Q Q 3 G G d l 21.REMARKS
County Parcel Ifdsentification No.(PK
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N w
6.Is are the well(s)oPermanent or 13Temporary Signature of Certifie�Contractor Date
By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an eiisting well: nYes or 9No with 15A NCAC 02C.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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I 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 Itst all depths tfdIfferent(example-3®200'and 2@1001 construction to the following:
10.Static water level below top of casing: (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: P (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.well construction method: r C �� 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) ! Method of test: b W 24c.For Water Supply&Injection Wells: In addition to sending the form to
1 I the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 7 Amount I `� • completion of well construction to the county health department of the county
where constructed.
Porm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016 }•