GW1-2021-04281_Well Construction - GW1_20210901

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor' !( I/nforrm� on:
) n (�e��,I„�, 14 WATEWZONES F;
11 FROM TO DESCREMON
W N Well Contractor Name fG 0 i
q3 V 2 h �a�Q ft
NC Well Contractor Certification Number 15.OUTER CAS G'foi multi wells`OR LINER rf a" ble
rr 11 (' L FROM TO DIAMEI'Fdt MCENESS MATERIAL
\I ono(��f 3 ft. 6 is Ia` VGfi4 I�d
Company Name
`j— .16.INNERCASING.OR`-TUBING 'tber°nldmed
2.Well Construction Permit#: 3 J,r "''f/�t FROM TO DIAMMETTFat 1HICISNESs I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft fL in
3.Well Use(check well use): ft ft
Water Supply Well: 17 SCREEN _
FROM TO DIAMETER SLOT SIZE THIC104us MATF�tiAL
Agricultural [3Municipal/Public 0 ft. ft in.
Geothermal(Heating/Cooling Supply) ffResidential Water Supply(single) ft. ft in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT-
Irrigation FROM TO MATERIAL' E MPLACEM NT METHOD&AMOUNT
Non-Water Supply Well: D ft. l_.(J R Y
Monitoring Recovery ft &
Injection Well:
ft ft
Aquifer Recharge Groundwater Remediation
19 SAND/GRAVELPACK da licabli
Aquifer Storage and Recovery D{Salinity Barrier FROM TO MATFutAL EMPLACEMENT MKMOD
Aquifer Test C]Stormwater Drainage ft. ft
_ Experimental Technology Subsidence Control fL ft
Geothermal(Closed Loop) 13Tracer 20 DRILLING LOG'sttacb additional etieeis ifnecessa
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DES Orr color,hardness,soivtock size,ere
O it A�fL
S l G u
4.Date Well(s)Completed: 2' Well ID# L)/D ft S
5a.Well Location: ft ft ,
/ ft ft
1rCt.n4V I AJ 1 a f�d I"�f S \ 1 g
Ficility/Ownef Name Facility ID#(ifapplicable) ft ft
z4b(i iron � � „ s, ,l,P Oce,<,,rg Ulu t
Physical Adds, ,City,and Zip ft. & [�}WR Sc'`tt1011
ram I n 216REMARKS_
County Parcel Identification No.(PIN) / l AX e,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification: /
N W
6.Is(are)the well(s)zPermanent or OTemporary Signature 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: 13Yes or JNo 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 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: 2 Y, (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 1@100) construction to the following:
10.Static water level below top of casing: 20 (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.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: C) cl,,r�/
above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) �- Method of test: ✓ 24c For Water S°mDly&Iniection�Wells: In addition to sending the form to
y� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: { Amount: JLA completion of well construction to the'county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016