GW1-2021-01919_Well Construction - GW1_20210415

I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name ti ^-- FROM TO I DESCRIPTION
ft. Z �. 3 m
APR 5 2021 ft. ft.
NC Well Contractor Certification Number U FR MUTER CASING or m DIAl1 se
d wells OR LINER a lica6le '
�f II JI (� p�l0]?QCES;ICII TO TER THICKNESS MATERIAL
�� I��vV 1 1 Y �+ 'r`=�0 +;ten � ft. / Oft. / ' 1n. ��
Company Name 1 I � V'
r� �y 1 /� 16,INNER CASING OR TUB G eothermai closed 100
2.Well Construction Permit#: E Lo- 00 1 00 Z FROM TO DIAMETER THICIGMS I MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. 00 , in' t✓
3.Well Use(check well use): ft. ft. in
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
Agricultural OMunicipal/Public Q ft. It. is
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
lndustrial/Commercial Residential Water Supply(shared)
18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: b % p ft �h In14�-
:)Monitoring ;Recovery ft. ft
Injection Well:
Aquifer Recharge OGroundwater Remediation ft ft
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer .20,DRILLING LOG attach additional sheets it'necessa
Geothermal (Heating/Cooling Return Other lain under#21 Remarks) FROM
ft TO DESCRIPTION color,hardness soft/eck type,amin size etc.
ft '�-fv ('
2 Well 1D# ft. 5 o it. VVr n v
4.Date Well(s)Completed: // yV��
5a.Well Location: 5 ft. Z ft. SWA C V
I M S PI Rai ft. ft.
Facility/Owner Name Facility IAD1#((iifapplicable)q ft. ft.
4111 m N�YV1'�.0 Z RU t o Al I V Z� 1� ft. ft.
Physical Address,City,and Zip I
21.RFAWARKS
County Parcel Identification No.(PK ( 0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: S S 6Tt
(ifwell field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s) ermanent or Temporary 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: E)Yes or No with 15.4 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.
filled' /�Q SUBMITTAL INSTRUCTIONS
L 9.Total well depth below land surface: Uo OL) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths If different(example.3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing: 20 (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
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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: n w t 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: D V y 24c.For Water Supply&Inlection Well's: 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