GW1-2021-06506_Well Construction - GW1_20211027

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WELL CONSTRUCTION RECORD (GW-1) 1 For Internal Use Only: ,
1.Well Contractor Information:
�aY� T 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
.� gft. .25- ft. rL ro c
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a livable)
`\t r FROM TO j DIAMETER THICKNESS MATERIAL
Company Name _I � ft• 'k3l ft- in. 6-6(1 Vex'J ze .
16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: r r Irk 6re5 l y(D-0u a3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft,
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO I DIAMETER I SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) sidential 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: (7 ft. ft. 5 ; 1
❑Monitoring ❑Recovery
Injection Well:
❑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) FROM TO DESCRIPTION(color,hardness,soil/rock type, in size,etc.)❑Other(explain under#21 Remarks) © ft. ft. SDj
4.Date Well(s)Completed: Ul -,,>,\Well ID# et. ft. S r �- 10
5a.Well Location: I ft. -A n p G 14
h
Facility/Owner Name Facility ID#(if applicable) t'�ft. / ft• Y� G 1 a
�� NL" G ft. �'�l�fL V�l [Yl�`i
Physical
�Address,
,City,and Zip (� 9/� ✓� n^� ft. ft. 1
•f 1 l�t tl VCI- 16 y ' 1-I 13`� 1 21.REMARKS nil
County Parcel Identification No.(PIN) Degging
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Inla��'3 R$ecrio
(if well field,one lat/long is sufficient) 22.Certification:
5 , 3�L0(-j;a N ` !g . 5!5a l�lJ w W o WL94�
6.Is(are)the well(s):Aermanent or ❑Temporary Signature ofCer#ed Well Contrac r Date
By 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: �1o0 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@100')
(ftJ 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,16,17 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: ,v (in.) 24b.For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
1� Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: M�Gh �zl �m \ A-l rq 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
0(-N Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) W Method of test:
t
13b.Disinfection type: Amount:
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018