GW1-2021-04168_Well Construction - GW1_20210827

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
a* FROM TO DESCRIPTION
Well Contractors Na (. i
2 -� 76 —A �O�y v��,�
P� ` ft. ft. i
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wens OR LINER. a cable)
S %� , t?tOr'et�� FROM TO DIAMETER THICKNESS MATERIAL
!//t/ l&n t^ ft. ft. I in.
Company Name '16.INNER CASING OR TUBING eothermal dosed-loo
2.Well Construction Permit#: �t p FROM TO DIAMETER THICKNESS KATERL4L
List all applicable well construction permits(i.e.WC,Coun State,Variance,etc) ft. ft in.
3.Well Use(check well use): ft. ft. in
Water Supply Well: .17.SCREEN
FROM TO DIAMETER SLOT.SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft. `I ft. Z in. D
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared,,
18.GROUT
❑Irri ation ❑Wells>100;000 GPD FROM TO MATEP.IAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
)(Monitoring ❑Recovery 1-7 ft. ft.
Injection Well: 92
11 ft ! it.
-/
❑Aquifer Recharge ❑Groundwater Remediation ` /
-19.SAND/GRAVEL PACK Of applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. 96 ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soWrock type,grain size,etc
ft. ft s
t ft. ft.
4.Date Well(s)Completed: ;12 Well ID#� �2
Sa.Well Location:
ft. ft.
A-v
Facility/Owner Name �K/ Facility ID##(if
applicable) ft. ft
t ti D L/ / 10 C. ft. ft.
Physical Address,City,and Zip ft ft.
21.REMARKR
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat(long is sufficient) 22.Certification:
6.Is(are)the well(s):*ermanent or ❑Temporary Signature of CerW W 1 Contractfe Date
By signing this ,rm,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this 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 Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page Ito 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: C� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: l (ft.)
For multiple wells list all depths if different(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 246.For Injection Wells:Copy to!DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: � L 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,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
13a.Yield(gpm) Method of test: Permit Program, 1611 MSC,Raleigh;NC 27699-1611
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13b.Disinfection type: Amount:
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources f Revised 6-6-2018
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