GW1-2021-06497_Well Construction - GW1_20211027

Wk;LL COINSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
-sy L 14.WATER ZONES
Well Contractor Nanle FROM TO DESCRIPTION
Aft � ft a
ft ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells OR LINER(if a IIcable
, �,`t (N C FROM TO DIAMETER THICKNESS MATERIAL
1 1 ft °a 1 ft in. �(7
Company Name n
2.Well Construction Permit#: 16. TO INNER CASING OR TUBING eothermal closed-fannI
FROM DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC.County,State, Variance,etc.) ft ft in.
3.Well Use(check well use): ft it. in.
Water Supply Well: 17,SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:_)Agricultural [3Municipal/Public ft fL a ia. O Jl�t vG
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
Industrial/Commercial oResidential Water Supply(shared) 18.GROUT
1rri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. oZ O ft
Monitoring ORecovery ft. ft J
Injection Well:
_ Aquifer Recharge Groundwater Remediation ft. ft
_ Aquifer Storage and Recovery In Salinity Barrier 19.SAND/GRAVEL PACK(if a licable
LI tY FROM TO MATERIAL EMPLACEMMMETROD
Aquifer Test EIStormwater Drainage ft a ft
Experimental Technology �ISubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) r.11Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soiltrock a grain sire,etc.)
ft 1 ft CJO 4.Date Well(s)Completed:3 �� .� Well ID# ft. "i fL t
Cl
5 .Well
Location: '"� ft• 2 ft. s 1
l�1 saA
�S Z 1 ft. ft. K e (ram
Facility/Owner Name Facility ID#(if applicable) ft. ft.
�?- lW `VY'n \ ?A1A '1JC 1�v ft. ft
P sical Address,City,and Z'p ft it.
!1 21.REMARKS
County Parcel Identification No.(PIN)
in�rrl',
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: En M ;i
(if well field,
rone
`�lat/long is susufficient) p 22.Certification
On
1D C;t , )L,04 -gy
N � IRo c
W 3-3-2-1
6.Is(are)the well(s) Permanent or QlTemporary Signature of Ce Vd Well Contracto Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or No with 15A A7CAC 02C.0700 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information explain the nature of the copy of this record has been provided to the well owner.
repair under 421 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: y (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'and 2®100� construction to the following:
10.Static water level below top of casing: I (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: l X (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: r r IU d � I(V� 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:
FOR WATER SUPPLY
Division of Water Resources,,Underground Injection Control Program,
Q WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) U Method of test: 24c. For Water Supply&Iniection Wells: In addition to sending the form to
`�-( 'J the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Y` I Amount: /y j 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