GW1-2021-02111_Well Construction - GW1_20210503

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
p i
`64 14.WATER ZONES I.
v FROM TO I DESCRIPTION
Well Contractor Name O ft. ft
prr'sued Contactor C}ertification Number 1e ft CecrNr tor.mti10-eased wells)OR LINER Ifappllcable)
// FROM ITO DIAMETER THICKNESS I MATERIAL
1(G m Q LJr'• D it. � ft. in. • r S( f
Company Na �i uD 16.INNER CASING OR TI7111[NG etJthermal dosed--loo` V
2.Well Construction Permit#: FROM I TO DIAMETER Talc MATEPJAL
List all applicable well construction permits(i.e.UIC,County,State,Yariance,etc) O ft. 1 D if C_
ft. ft. in.
3.Well Use(check well use): 11
17.SCREEN
Water Supply Well: FROM I TO I DIAMETER SLOT SIZE TRICKNESS MATERIAL
e n,:r„ttyra) OMunicipat/Public ft. ft. in•I
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared) IS.GROUT
,1"JIrrip,ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft' ZO
Monitoring :Recovery
Injection Well:
Aquifer Recharge oGroundwater Remediation 19.SAND/GRAVEL'PACK Ka 'lteable
Aquifer Storage and Recovery OSalinity Barrier I FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG:attach additional sheets if necessa
FROM TO DESCRTMON color,hardness,soiVrock n s etc.
Geothermal eatin Coolin Return Y Other(explain under#21 Remarks 0 ft. Z ft. ;�.� `
4.Date Well(s)Completed: -2(/—a/Well ID# ft. at
p ft. ft. h ro c
58.Well Location:
,cot �Ih bl�lrs Oft. f a� � ���07t, v Kok
Facility/Owner Name Facility ID#(if applicable) ft. ft.
tt. �-
ft.
Physical Address City,and Zip N I 't_ 21.REMARKS
County Parcel Identification No.(PIN) t
R,.
'on ProsesS1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: er J
(if well field,one lat/iong is sufficient) 22.Certification:
N W
6.Is(are)the well(s)G(Permanent or Temporary Signature fCcrtified well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: 13
Yes or No with ISA NCAC 01C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a
Ijthis 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 Geoprohe/DP 1 or Closed-Loop Geothermal Wells having tie 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: / SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I �D (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q1/00'and 2@100') 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: (in.) 24b.For Iniectton 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: _T 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: I 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) W Method of test: a w 24c.For Water SunDly&Injection Wells: In addition to sending the form to
L L the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: T h Amount: completion of well construction to the county health department of the county
=q:!�2where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016