GW1-2021-05497_Well Construction - GW1_20211013

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: Cam R�
n r
�S b 1'� i"bb 1 R WATER ZONES
F
1—w' FROM TO DESCRIPTION
Well Contractor Name ft,rL yt o L M
^ I I
0 P�7
ft. ft.
NC Well Contractor Certification Number EO=f 3 ttj t'JQG 15.OUTER CASING for multi-cased ivel6s OR LINER llcable)
C FROM TO DIAMETER THICKNESS MATERIAL
6 ft. S tL is •, 6g ,�1 v.
bma canCompany Name y� 16.INNER CASING OR.TUBING' eothehrmat closed-loo
2.Well Construction Permit#: t$3%0 + r rt'e I �'Y FROM TO DIAMETER TIUCKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ff fr' in. V C.
fL fL io.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER: SLOT SIZE I MATERIAL
Agricultural Municipal/Pablic ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. to.•
Industrial/Commercial DResidential Water Supply(shared) 1&GROUT
II7i atiOII FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: It. a 11. Y01 t
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK f applicable),
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary),
FROM TO DESCRIPTION color,hardness,sorVrock type,grain size etc.
Geothermal eaten Cooling Return Other lain under#21 Remarks O ft. G
iq
4.Date Well(s)Completed Well m# ft. it. r n L 0 G C,
tt. ft.
5a.Well Location:
Facility/ Name Facility ID#(if applicable) ft ft
bAtok W es Jr. t QI its Lir D
Ct. ft.
Physical Address,City,and Zip
C 1A G gCA 21.REMARKS
oat A L
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: D h q
(ifwell field,one lat/long is sufficient) 22.C tification•
06 N W
6.Is(are)the well(') Permanent or Temporary signatM of Certified well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or [JNo with 15A NCAC 02C.0100 or 15A 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 1 q SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 -(�) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@2200'mud 1@I00') 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"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: 1n 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: r� ' ` construction to the following:
(i;e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: / ,•t 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) d`� Method of test: `a W 24c.For Water Supply&Iniecdon 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: 2 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