GW1-2021-06560_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
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING([or multi-cased wells)OR LINER(if a Gcable
` T FROM TO DIAMETER THICKNESS MATERIAL
V'i I o G +r; ft. ft. in. <;Ch 'Q VL
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#• '�5sj p ( D I r7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. et. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. fL in- (�)a S(t_
,f 1 O v�
l
❑Geothermal(Heating/Cooling Supply) esldential Water Supply(single) ft. fL 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: ® ft. Oft- n
❑Monitoring ❑Recovery ft. ft.
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 (� ft. a ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑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,soiVrmk type,grain size,etc.)
In. / ft. D SQ
4.Date Well(s)Completed: Well ID# ft. q ft.
5a.Well Location: l q ft• ft. u IL G A
c
Facility/Owner Name ii , 'r'� I-Facility ID#(if applicable) ft. ft.
q OWN
1_I C if C�+n � lilt 1-n 6 e r l'i N-� ft. ft. 10
Physical Address,City,and Zip ft. ft. -In 01
T , S� D Q cl f o u o S9 21.REMARKS 3` B
County` ` Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
� r
6.Is(are)the well(s): taxermanent or ❑Temporary Signature ofCerti d Well Contract Date
/ 1
�� ''�. B��signing this form,I hereby certify that the we//(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 our known well construction information a d 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: 2h (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dii ferent(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"+"l'
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: MW A -21C)Ttk 0 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
13a.Yield(gym) 10 Method of test:
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
11
13b.Disinfection type: �1 �1 Amount: `
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018