GW1-2021-05342_Well Construction - GW1_20211013

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
•/' %q_n'` „ w® J4.,WATER ZONES,
Well Contractor Name Vib-p<
TO DESCRIPTION
3 �� � tioti1 NC WellCont�orCariificationNumbar qft. �
4�Cf�Ge "15.OUTER CAB multl-cased'wens.OA LINER Ira-llcable
FROM TO DIAMETER THICKNESS MATERIAL
C► ) L-C.((�f �=d '"'�n�r�J ft. ft. in. It
Company Name
16.INNER CASING OR TUBING eothermal ck1sed400DI,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i e.UIC,County,State,Variance,etc.) ft. ft. Qhh
3.Well Use(check well use): ft. ft. in.
Water Supply Well: x17:SCREEN
FROM I TO DIAMETER I sunsim, I THICKNESS MATERIAL
Agricultural OM icipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in
Industrial/Commercial Residential Water Supply(shared)
1&GROUT "
Irrigation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft-
Monitoring __Recovery
Injection Well. ft
Aquifer Recharge E3Groundwater Remediation
19:SAND/GRAVEL-PACH ifs-licable _ .. .
Aquifer Storage and Recovery DSalinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft•
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20 DRILLING,L'OG attach Addid2hal sheets if
Geothermal(Heating/Co li Return Other(explain under#21 Remarks FROM ft. ft.To DFSCRIVnoN fealor,hEo!M sauroek bVe,grain Sze,ete.
n
4.Date Well(s)Completed: q►-I6-2► Well '0&2 ft.
5a.Well Location:
k ft. ft.
Facility/Owner Name Fatality ID#(if applicable) ft. ft.
ex
ft.
Phys' afAddress,City,and Zip
2L REMARKS;
trN
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) /� D 22.Ce lion
6.Is(are)the well(s) ermanent or LITemporary LSi9GtiqfofCertifie, wellC-011peler Date
s By signing this form,I hereby certify that the weU(s)was(were)constructed in accordance
7.1s this a repair to an existing well: ®Yes or' with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this 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 detafs:
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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SLI13MTITAL INSTRUCTIONS
9.Total well depth below land surface: �`L� (R•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welts list all depths if different(example-3Q2000''and 2Q100') 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"+^ f"j 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. / (in.) 24b.For Iniection Wells: In addition to sending the forth to the address in 24a
�12.Well construction method: �w above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,_iotary,cable,direct push,etc.) i
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: .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: Amount: Jf&&a1 g4 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