GW1-2021-06495_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KA�/�`W + 14.WATER ZONES
Well Contractor Name y FROM TO DESCRIPTION
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a livable)
vl� FROM TO DIAMETER THICKNESS MATERIAL
1 �\ \ `11( ft. ft. in. P�
Company Name
FR INNER CASING OR TUBING eothermal closed-ES
2.Well Construction Permit#: � FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Counh',State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in•
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT_SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public t. ft. in• _r O Pvc.
[]Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
Oh-ri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 09 t
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. aft. A,
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiurock type,grain size,etc.)
l D ft. ft.
4.Date Well(s)Completed: Well ID# ft. et.
5a.Well Location: ft. ft. L• tA
, fL 6t h 1' e G G
Facility/Owner Name Facility ID#(if applicable) XL 3i„ft- wn
f I ft. YY��ft.
Ph sical Address,City,and Zi I v�u�d ft. ft. go 2
a �tM V-In 1\ non '�v��_t fU2-7 21.REMARKS V t l)
County V 1 I tAt Parcel IddeeyntificationNo.(PIINN) :Zl�"�t�B J �1011
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) I _Q 5 22.Certification:
6.Is(are)the well(s): ermanent or ❑Temporary Signature ofCertV11ed Well Cont ctor Date
��� Av signing this form,I hereby certifi that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or -60 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information a d explain the nature ofthe 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 construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
2
9.Total well depth below land surface: . L2 A) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-`3}�200'and 2 @I00')
t V (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells: Copy to DWR, Underground Injection Control (TUC)
11.Borehole diameter: (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
]
Um 't Permit Program, 1611 MSC,Raleigh,NC 27699-161 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: t Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018