GW1-2021-04169_Well Construction - GW1_20210827

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
an V `+y 14.RATER ZONES.
Well Contractor N e
FROM TO DESCRIPTION
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NC Well Contractor Certification Number r (� AS..OUTER'CASING for mtiltl-cased'webs OR LINER: a"licable
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FROM TO DIAMETER TffiCKNESS MATERIAL
Company Name
16aINNER'CASING,ORTUBING `eothermal used=rod
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: FROM
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ®Oft. it. in. �!
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) tt. tt. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared)
1g:;GROUT'
❑Irrigation ❑Webs>100,000 GPD Fmftft.
MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: AConitoring ❑Recovery Injection Well: __
❑Aquifer Recharge ❑Groundwater Remediation u
193AND/GRAVEL PACK a cable.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLINGLOG attacb sidditiooal sheets'tf necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM ft ft.
To DESCRIPTION color,hardness soil/rock in s etc.
.
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4.Date Well(s)Completed: Q��L Well ID# ft. ft.
5a.Well Location:
Facility/Owner Name Facility ID#(if applicable)
e�4 a/w ../Il
Physical Address,City,and Zip ft. ft.
21.REMARKS'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one tat/long is sufficient) 22.Certification:
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6.Is(are)the well(s):*ermanent or ❑Temporary Signature of C75,,m,
W 1 Contrac Date
By signing this hereby certify that the well(v)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 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 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: (ft.) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100)
/ 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: !1. (ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" I
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)_ Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 5a t2 j e 24c.For Water Supply and Open iLoop 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
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources; Revised 6-6-2018

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