GW1-2021-06664_Well Construction - GW1_20211007

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
a
FROM TO SCRIPTION
Well Contractor Name � DE V 5 T' ft. -7� rt alCC S o
31
,3+itprC �E� A� It. ft.
NC Well Contractor Certification Number, \, O(1 15.OUTER CASING for multitased wells OR LINER if a licable
W Wv FROM ' TO DIAMETER
. THICKNESS MATERIAL
nay / ft. ft ,
_TT UC
Company Name 16.INNER CASING OR TUBING 'eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(I.e.UIG Countv,State, Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
17.Water Supply Well: FROM
OM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public stt 7 ft it!in // vC
❑Geothermal(Heating/Cooling Supply) feiRE5i'dential Water Supply(single) ftft. in. V
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: J ft ft. C[Q - o ulf-
OMonitoring ❑Recovery ft. ft
Injection Well:
tt ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft -71 ft- - Po Vr-
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soll/mck type,grain size,etc.
ft f S ft
4.Date Well(s)Completed: y.a Well ID# ''r ft J fL
5a.Well Location: ft. it.
�c�0 6FU����� ft ft
Facility/Own�err Name Facility ID#(if applicable) it ft
4 -i 0� �15T- f"(ACQ. S� 6ibl UI ff a.4 ft ft
Physical Address,City,and Zip ft. ft
PITT `,.� 21.REMARKS
Parcel Iden`ttY cation No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one)latllong is sufficient) j�`�Q 22.Certification:9S'.7Sr71LA N-7�7 / I VV
6.Is(are)the well(s)• �nent or ❑Temporary Signature of Certified Well Contractor, Date
By signing this form,I herebv certifv that the well(s)was(were)constructed in accordance with
7.Is this a repair.to an existing well: ❑Yes of 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction:Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the 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 GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box):You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7-7 (ft) Submit this GW-1 within 30 di
ys of well completion per the following:
For multiple wells list all depths iJ different(example-3@200'and 2@100)
I 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit, 1617'MSC,Raleigh,NC 27699-1617
If ivater level is above casing,use
1 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 1 ►1 V 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.augger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA.
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) So Method of test: 1
13b.Disinfection type: a`(q�-L Amount: -) 0
Form GW-1 North Carolina Department of Environmental Quality-Division of water Resources Revised 6-6-2018