GW1-2021-06548_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
rt. rt. +r,,yl r
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if ap licable)
1
` I ` FROM TO DIAMETER THICKNESS MATERIAL
1 ft. ft. in. I
Company Name V
16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: FROM I TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,Count),,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 9dt l ft. �t- in. 01 v
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Walls> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: © ft. Q R. 5v
❑Monitoring ❑Recovery
Injection Well:
[]Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMEN'TMETHOD
❑Aquifer Test ❑Stormwater Drainage 9 0
❑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,soilhmck type, rain size,etc.)
ft. ft. S O 1
4.Date Well(s)Completed: 1 Well EN ft. !/ ft. rN ` A
5a.Well Location: ft. ft. cre ?re- Col&' 1&
^�e.rYU �Q 1^ 3 ft. Ll 01
ft. a n C-Ikq
Facility/Owner Na a Facility ID#(if applicable) 1- l ft. (I ft. 1�5Ole Ot
lJby ll c\ tsa Y1 �?WLI t2 ft. ft.
Physical Address,City,and Zip
t, n 21.REMARKS
County �.X Parcel Identification No.(PIN) It
Informat ion P1tJC0Q5iFl@
., n
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
�3S � 3:J VQ N''�q. �F�-111� W -7_-�
6.Is(are)the well(s): irmanent or ❑Temporary Signature ofCertifi Well Contracto Date
//'_ B),signing this form,!hereby certifi,that the ivell(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 td 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: 010 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths rf different(example-3@200'and 2@100')
3e7 ft. 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" ssi Static water level below top of casing: ( ) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
lJ `
11.Borehole diameter: (in,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(RUC)
,^� , Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: `y` A 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) ,l Method of test: I t"6'
13b.Disinfection type: �_ t Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018