GW1-2021-06549_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES 1.
Well Contractor Name
j� FROM TO DESCRIPTION
311.
�j�
ft. 1 ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a livable)
;"\ r `�` �l `l I'y� FROM TO DIAMETER THICKNESS MATERIAL
\ t- ft. I •a3 ft. I q in. \J�_
Company Name
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.UIC,Count-Y,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public aft. kA a, ft. in. $ S..h L It O P4L
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑ Lk
/❑_Residential Water Supply(shared) 18.GROUT
❑lrri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. Q ft. 9Jedo-4 t 'O
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(it 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,soil rock type, rain siu,etc)
O
4.Date Well(s)Completed: lX Z, Well ID#
5a.Well Location: of ft. .21
P h IA �2 1n. 33 ft. A r\ 1/VA (, e j a
Facciility/Owner Na !mn 1 ( ` , Faei ID#(if appliclabtle) 3 t. OM
aft G�YI Ste,
ft.
ft.
Physical Address,City,and Zip R 839,17
� ft. ft.
1C,t`
1 k_ Ot U 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: DWR$3Cibn
(if well field,one lat/ionnpg is sufficient) , p-�( 22.Certification:
74 t
r 1 �`�u'I j N c ►o_1 t W 0�
� w
6.Is(are)the well(s)' rmanent or ❑Temporary Signature ofC6fified Well Contr for 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 coP),
1f this is a repair,fill out known well construction information nd 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: -i Z-- (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(TUC)
1 `{� Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rn C� x✓ 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(gym) Method of test:
D Permit Program, 1611 MSC,Raleigh,NC 27699-1611
t ��Y
13b.Disinfection type: A 1 Amount: 1 W d
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018