GW1-2021-06502_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
1 `' 14.WATER ZONES
Well Contractor Name , FROM TO DESCRIPTION
� 5 ft. a ft. c,Qayse, furts�
v 202� ft. ft.
NC Well Contractor Certification Number � 1- 15.OUOTER CASING(for multi-cased wells)OR LINER(if a livable)
M TO DIAMETER THICKNESS MATERIAL
1 �ec�$Elti9 in. (.,h D Y
P y CwY'� Sect10 L
Com an Name (� V YR 16.INNER CASING OR TUBING(geothermal closed-loop)
J O� 1.- FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: (
List all applicable well construction permits(i.e.TJIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 0 �ft. OZ ft. �''in• `O1
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
R
❑Industrial/Commercial tMesidential Water Supply(shared) 18.GROUT
❑liTl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: © ft. �Q ft. b
❑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 C ft. 21
Cam,
❑Experimental Technology ❑Subsidence Control ft. _1 ft. �Lt
❑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,soil rock type,gmin size,etc.)
4 D ft. ' ft. 50)
4.Date Well(s)Completed: D r I Well ID#
5a.Well Location: Gl ft. 1 ft. f1 C lr�
US2e1rV5l�-A ^, ?"T" _t.�pht' GICt
Facility/Owner Name (� n F,acillityy ID#(if applicable) 1 d 5- ft. 2-G` ft. D(J�1/S e n SA n
dl
11L5Ot 4 C ao'( O aK- \vie l C�IX VArP e_�;1 Ls ft. fL
Physical Address,City,and Zip
21.REMARKS
County IJU\ Parcel Identification No. I )
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lonnlg is sufficient) Q Q q Q 22.Certification:
✓q tqo 1 W, N ` V0 t �0 ill � W
6.Is(are)the well(s): E)I&rmanent or ❑Temporary Signature ified Well Contfactor Date
Av signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or No 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 and explain 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (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@I00')
13 (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:'(-nya' ILAIG1,111 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
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) u Method of test: O ,(��t�
13b.Disinfection type: r` Amount: t �1
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018