GW1-2021-06543_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 1/
14.WATER ZONES
«
FROM TO DESCRIPTION
Well Contractor Name
� ft. 41 ft. �vS Cv � s
Q$U3 ►�
ft. ft.
NC Well Contractor Certification `Number 15.OUTER CASING(for multi-cased wells)OR LINER if a Gcable)
FROM TO DIAMETER THICKNESS MATERIAL
Y(�•J -} ft. 3, ft. a in. S�' p�L
Company Name
�3` 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C.County,State,Variance,etc.) +ft
in•
3.Well Use(check well use): ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3'7 ft. q1 ft. in. �D1Q yu
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft. ft. of in.
❑Industrial/Commercial mResidential Water Supply(shared) 18.GROUT
❑hTi ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: R. a(D ft. Z S- Y'
t
❑Monitoring El 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
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks)_J
FROM TO DESCRIPTION(color,hardness,soil rock type,grain size,etc)
0 ft. /1 ft.
4.Date Well(s)Completed: -/�-c) Well ID# A rt. O�
5a.Well Location: ft. red I S ac(
C
Facility/Owner b9me Facility ID#(if applicable) ft. ft. ax V e C4
A > N SDI ms N( )93)7
Physical Address,City,and Zip ft. ft.
t� 21.REMARKS
County X 1 Parcel Identification No.(PIN)
,at;on troy , ,
wig
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one hit/long is sufficient) r�q 22.Certification:
3� - Cf D 1/l isl
0 l-31 N 1 1 r c1�)t�Qa W d('/ � i r
6.Is(are)the well(s)' 96rmanent or ❑Temporary Signature of Ceh fled Well Combictor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 0 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 aAdxplain 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: q (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')
1� (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"+"
11.Borehole diameter' (in,) 24b.For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
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.) Jcounty 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) Method of te t: Permit Program, 1611 MSC,Raleigh,NC 27699-1611
s `Yl I
13b.Disinfection type: Amount: 1/1,4
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018