GW1-2021-03898_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Weti Contractor Information:
14.WATER ZONES
y y, FROM TO I DESC IPTION
Well Contractor Name ft. (� It. Fes►
h. rt.
NC Well Contractor Certi5caWm`e er 1 /►.� 15.OUTER CASING for meltitased wells OR LINER if a licable
FROM TO ETER'S TAIL KNESS MATE
R• ft-
DIAMRAAI.
IN
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: WFROM
TO DIAMETER THICKNESS MATERIAL
LW all applicable well corrtrucno+ Krm 4 0 e. UIC.Count)',State, Variance,etc.) ft' in.
ft. is
3.Well Use(check well use):
Water Su Well: EN
PPh' TODIAMETER SLOT SIZE THtC "ESS MAAgricultural OM icipaUPublic /h, ln. ` 'flu VVGeothermal(Heating%Cooling Supply) esidential Water Supply(single) v R. in,
industriaUCommersial Residential Water Supply(shared) 18.GROUT
tint ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (� ft. ft. O�
Monitoring Rj ,ery h. h.
Injectio Well: fr. ft.
Aquifer harge Groundwater Remediation
19.SAND/GRAVEL PACK applicable)
Aquifer Stora d Recovery Salinity Barrier FROM TO MATERIALEMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technolo Subsidence Control ft. ft.
Geothermal(Clos P) er 20.DRILLING LOG attach additional sheets if
Geothermal(H tin Coolin Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,wlUrvck t is ere.
h. h• �J f�/
4.Date Well(s)Completed: D W Well ID# 3ft' 1 ft Q �t2 �t
ell Location:
nAkh n fr.
Facility/Owner Name Faciliytyy I,D/#�(ifapplieable) ft, a
U( cl T= cnk /
�t . I V I/l� 1�r LL� 1`l/ h.
Physical Address,City,and Zip ft. h,
k
County 2L REMARKS ,
1
Parcel Identification No.(PIN) r•, r r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
0fwcll field,one latllong is sufficient) 2L Certifieado .
6.Is(are)the well(s) ermanent or Temporary Signature of Ccttified Well Contractor Date
/ By signing this form,I hereby certify that the aellfs)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or [!31MO with 15A NCAC 02C.OJ00 or 15A NCAC 01C.0100 Well Construction Standards and that a
Ifthis&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:
S.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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 00 Division of Water Resources,Information Processing Unit,
1fwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection 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.WeB construction method: 044"1 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 Center,Raleigh,NC 17699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supyft&Inlection Wells: In addition to sending the form to
n the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 2zcAmount: 0 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