GW1-2021-06500_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: 1/
kzmh14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft. ira
I(O V�� 0CT 2 7 2021 ft. ft.
NC Well Cg 6orenification Number V .OUTER CASING(for multi-cased wells)OR LINER if a 0cable)
pro ssln9
Ge FROM TO DIAMETER THICKNESS MATERIAL
� 3tt0i► ft. 35 ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: rnJ y FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,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 >S't. �C)ft. a in. O 1a � PV�.-
❑Geothermal(Heating/Cooling Supply) �Idential Water Supply(single) ft. ft. In•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD$AMOUNT
Non-Water Supply Well: © ft. ft. 1 b%`
❑Monitoring ❑Recovery ft. ft.
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
❑Experimental Technology ❑Subsidence Control
❑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,soillrock type,grain size,etc.)ft.
4.Date Well(s)Completed: �3 2 I Well ID# et. ft. Clu
5 Well Location: ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. '
Physical Address,City,and Zip 35—ft. iry ft. n
21.REMARKS tJ
County Parcel Identification No.(PIN))
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well
field,one lat/long is ssufficient) Q �(R 22.Certification:-3 1 t1 U 1su N JJ�� W t
6.Is(are)the well(s): []Permanent or ❑Temporary Signature of Ce ed Well Contra r ^� Date
By signing this form,1 hereby certifi'that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 00 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
1f this is a repair,fill out known well construction information ald'eexplain the nature of the 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: lio 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 `� (ft.) 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@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (in.) 24b.For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
71 \+ _ Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:m ILk 1� hi Y 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
13a.Yield(gpm) l
` u Method of test: Permit Program, 1611 MSC,Raleigh,NC 27699-1611
l
13b.Disinfection type: I `-Ttr1 Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018