GW1-2021-05557_Well Construction - GW1_20211013

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Q. 14.WATER ZONES
FROM TO DESCRIPTION
We1l1Contrac't`o�rName � ft. TO
d
Ut111 ft. %
NC Well Contractor Certification Number �S�r�ti��
15.OUTER CASING for:inultl-cased wefts)OR LINER(if sop Hcable)
r� a ��v '1 FROM TO DIAMETER THICKNESS
MATERIAL
V i r ay QO a i W�� ` (:• 'Cl - ft. Or ft. in D /�
Company Name ' 4il
- ��4y_ a o ao FR TNNEFfCA$1 OR TUBING eirthermal closed=too
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Counv,State, Variamte,etc.) ft• ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: I .5CREEN.
FROM TO DIAMETER SLOT SUE THICKNESS MATERIAL
:)Agricultural unicipallftblic ft.' ft.` in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
:)Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
_11triRation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it. Q iL �
Monitoring Recovery ft. ft
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL PACK a" Iicable
Aquifer Storage and Recovery Salinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage `ft. '°&
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRI1LLING100G`attach.additional sheets ffnecess
Geothermal(Heating/Cooling Return) nOther(explain under#21 RemaricL)_J
T
TO DESCRIPTION color,hardness,sall/rock in size eta
1 ft. C4.Date Well(s)Completed: We1lID# / A ft.
5s.Well Location:
igio 61t 'hft ft. ft.
Facility/OwneiName Facility ID#(if applicable) n• ft.
033 5 6k Glen
Physical Address,City,and lip '1]1REMARKS
ft. tt.
h r ^^� ► 17 _21.RE�S MARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lavlong is sufficient) 22.Certii ation• J)
N W /V
6.Is(are)the well(s) Permanent or Temporary Signature Certificd Well Contractor Date
By signing this form,I hereby cert6 that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: dyes or [3No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fdl 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: J r'o (ft-) 24a. For A11 Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if&fferent(example-3@200'and 2@100� construction to the following:
f
10.Static water level below top of casing: 2 0 ,L) Division of Water Resources,Information Processing Unit,
If water level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: in _(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.Well construction method: rfi construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Ceuter,Raleigh,NC 27699-1636
13a.Yield(gpm) r+ Method of test: low 24c.For Water SunDiv&Iniecti n Vells: In addition to sending the form to
1 the address(es) above, also submit tine copy of this form within 30 days of
13b.Disinfection type: Lilk Amount: • completion of well construction toy the county health department of the county
where construc[ed.
Form GW-1 North Carolina Department of Environmental Quality-Division of!Tinter Resources Revised 2-22-2016