GW1-2021-05423_Well Construction - GW1_20211013

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WELL-CONST-RUCT�=ON41EEORI3-(GW-1) , For-Intetmal T T e-Only: --- --
1.Well Contractor Information: � ���'�•
'M o n poblk 14.WATER ZONES
Well Contractor Name
((``j R t FROM TO DESCRIPTION
ft. 0¢§ft.
Ul�it
pror'e rt ft.
NC Well Contractor Certification Number try^ 0t�n
��+�I�' n;p� �CL'On ,//�� i5.OUTER CASING(for mu161-cased wells 0R1:INER.ifa licable
l�Q �6 � �� � FROM TO DIAMETER THICKNESS MA '/W �fJ 6
Company Name
/p�] 16.INNER CASING OR TUBING(geothermal dosedaoo
2.Well Construction Permit#: �10 L q FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(1.e.UIC,County,State, Varid leR,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
17ft-
TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Ptiblic Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. in.
Industrial/Commercial [3Residential Water Supply(shared) 18.GROUT
Irri ation FROM I TO LITERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft 0 ft C M Al
Monitoring Recovery ft. ft.
Injection Well: ft. ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicahle)
Aquifer Storage and Recovery Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test OStonnwater Drainage "=ft.% At
Experimental Technology Subsidence Control
Geothermal(Closed,Loop) OTracer 20.DRILLINGLOG attaihaddidonalsheeitsifnecessa R '
Geothermal(Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color hardness,solltrock n size,etc.
m ft 2, ft. s e f
4.Date Well(s)Completed: Well ID# 1 ft. © ft.
5a.Well Location: ft. ® ft.
�+ y, /C�7nq L ft. ft. '
}y QI
Facility/fOwnerName Facility ID#(ifapplicablee))
1061 6AA1Vl.' �� f W�rfJtQ . �Z { ft ft
Physical Address,
City,and Zip fL ft.
J®h t'I i liJ'1 21 REMARXS'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlong is sufficient) 22.Certification.
N W
6.Is(are)the well(s) Permanent or Temporary 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-existin g well: []Yes--or� No with:15A NCAC 62C.0100 or 15A NCAC 01C.0200 Well Construction Standards mad 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: O 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d(ferew(example-3@.700'mad 2@1001 construction to the following:
10.Static water level below top of casing: 2a (ft.) Division of Water Resources,Information Processing Unit,
If rester level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I
ll.Borehole diameter: (in.) 24b.For Iniection 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: ( iJ `r'J' construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: fr t 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: l�"`s 24c.For Water Supply&Iniection 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: completion of well construction to the county health department of the county
where constructed.
Form aw-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016