GW1-2021-04280_Well Construction - GW1_20210901

t:1 rI I L I%J1I II
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
L-Well Contractor Information:` /
at,, ` N GI 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
d__C13� ft. ft.
�CIC�11 ((�� ft. ft.
NC Well Contractor Certification Number / 15.OUTER.CASING for mul&cased wells OR LINER if a` licable)
rah Pn� t, Well i �u FROM TO DIAMETER THICKNESS MATERIAL
W ft. ft in. v C.,Company Name
n ' 16'.INNER CASING OR TUBIN eothermal dosed400
L h
2.Well Construction Permit#: ( 1 t 5 FROM TO I DIAMETER I THICKNESS MATERIAL,
List all applicable well construction permits(i.e.UIC,Count,State,Variance,eta) ft. ft. in.
3.Well Use(check well use): ft. ft. to.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:]Agricultural Municipal/Public ft. ft. in. :
Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Ini ation FROM TO MA L EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ;
he
:Monitoring DRecovery fa ft.
Injection Well:
ft. tt.
Aquifer Recharge oGroundwater Remediation
K:
Aquifer Storage and Recovery Salini Barrier
19;SAND/GRAVEL PACf alicable
tY FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage M ft•
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets ifneeessa ,
Geothermal(HeatinglCooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION color hardnwA sollfrock type,grgin size etc.
Q I 0
4.Date Well(s)Completed: v 1 I Well ID# a ft. b ft. AtNait
5a.Well Location: ft it I,,, ,,� ,o� •sue;
`rbbl n Com sF ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft. qFp '
M Doc, NicLols Our Low NL a77y3 ft. ft.
Physical Address,City,and Zip ft. ft.
si
!./ut"re,t P y 1 21 C`ar i
.REMARKS.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwefl field,one IaVlong is sufficient) 22.Cc c on:
N
6.Is(are)the wells) Permanent or OTemporary Signa of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or gNo with ISA NCAC 02C.0100 or 15A NCAC 02C.0100 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 421 remarks section or on the back of this farm.
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: 0o (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: Z 0 (ft) Division of Water Resources,Information Processing Unit,
Ijwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service CcInter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: d 24c.For Water SuDDIv&Iniection Wells: In addition to sending the form to
L the address(es) above, also submit' one copy of this form within 30 days of
13b.Disinfection type: Amount: J• completion of well construction to`the county health department of the county
where constructed. E
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i` Revised 2-22-2016