GW1-2021-05531_Well Construction - GW1_20211013

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
/ 1.Well Contractor Information: ?
at. \� AM\ 14.WATER ZONES-
Well Contractor Name 1 L''— FROM TO R DESCRIPTION��
3a2 1->, A 1 �Q;,\�g
NC Well Contractor Certification Number O+� cJo G1�0(� 170 V
ft. ft. I/b.
i3OZt' �,R 'd3cOITI'ERCASING'tbrinoltl=cased-wns;ORLINER Ito-llcable '" '`""•""""
PM
FROM TO DIAMETER I THICKNESS I MATERIAL
(03 ft. 6,A6 in.
Company Name 16.INNER CASING'OR TUBING( eothermal closed400
2.Well Constriction Permit#: FROM TO I DIAMETER F THICKNESS I MATERIAL
List all applicable well construction permits(i e.UIC,County,State,Variance,etc.) ft. ft. I j n
3.Well Use(check well use): ft• It. in.
17:`SCREEN
Water Supply Well: FROM I To DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural 13 unicipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) (Residential Water Supply(single) ft. ft.
Industrial/Commercial DResidential Water Supply(shared) 1s:,GROUT L
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft• bs ft- 319
Monitoring __Recovery ft. ft. ` !
Injection Well: ft ft 0U
:)Aquifer Recharge Groundwater Remediation 91 hen 19.SAND/GRAVELPACH rf a'Itcable
If Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.'DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) ,Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardnem soiurock etc.
fL ft'
V lit!
4.Date Well(s)Completes: &-31_2 I Well ID# ft• ig ft•
Sa./Well Location:
Facility/Owner Name Facility M#(if applicable) ft• ft.
Physical Address,City,and Zip ft
C 11.REMARKS. ;
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or deck mi degrees:
(if well field,one]]at/long is sufficient) ! �p �(� /' I V//� 22.Certification:
r`N I °"l o�� lC W
6.Is(are)the well(s)63 ermalrent or OTernporary "TigntufeofCerfified Well r 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: E3 Yes orp<o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,ft/1 out brown well construction information and explain the native 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-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: 19Q (ft•) 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'an 2@I001 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"+"t f 6 1617 Mail Service'ICenter,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 constriction method:
�� y 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 Mall Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �_� Method of test:Q/�r�tJn �d>M e.For Water SuDDIv&Iniection Wells: In addition to sending the form to
address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 9 &A.%tGS 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