GW1-2021-03780_Well Construction - GW1_20210823

1 Ill ll l VII
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well� Contractor Information:
' Ji//"9./ 14.WATER ZONES
Well Contractor Name FROM TO DESCRTIONO ft. 'rJ ft. ��� .S
44 A5 �
(t. ft.
NC Well Contractor Certification Number 15.OUTERCA ING for multi-cased wells OR LINER if a licabler ,n, /�� ('f� 2Cm62
k FROM DIAMETER FTHICKNESS MATERIAL
Company Name
16.INNER CASING OR TUBING(peother al closed-loop)
2.Well Construction Permit#• FROM TO DLNiETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.111C,Count)-,State. Variance,etc.) ft. ft. in.
3.Well Use(check well use): H. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS I MATERIAL
Agricultural Municipal/Public v ft. rj ft. Z in. v 4
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft' ✓ ft. in. 7
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
rNon-Water
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
upply Well: D ft. P Recovery ft.11:harge Groundwater Remediation19.SAND/GRAVEL PACK if a licableage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage lr' tt. ft. / ... ✓11,
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FlOther(explain under#21 Remarks) FROM TO DESCRIPTION color bardn soit/mck tyve,gnin sbe,etc)
4.Date Well(s)Completed: V Well ID# ft. rt• C
5a.W 1v ►V1ell Locationn /]:�� L p fir. v ft. et f' 4l
Lim iv-
Facility/OwnerNamc Facility 1D# ifapplicable)A fit. fir. 't:Y
ft. fit. �"•�"`'
Physical Address,City,and Zip ft.
21.REMARKS
County Parcel Identification No.(PIN) NWH ...,,*K ,,IC'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
N W �..� (cc <6
6.Is(are)the well(s)fflPermanent or UTemporary Signature ofOnfificd Well Contractor Date
By signing this form,I hereby cerrrfi,that the Kell(s) was(were)corutrucred in accordance
7.Is this a repair to nn existing well: Oyes or O rvilh 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis is a repair,fill out known well construction information and erplain the nature ofthe cop)gfthis record has been provided to the well owner.
repair tinder#21 remarks section or on the back o(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.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@1109 construction to the following:
10.Static water level below top of casing: V (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.j n 24b.For Injection Wells: In addition to sending the form to the address in 24a
n /`_ G,r.) above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: vJ w
(i.e.auger,rotary,cable,direct push,etc.) construction[o the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: '0'JAT.J 24c.For Water Supply&Infection Wells: 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: C 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