GW1-2021-06567_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
a_f- 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft ftUQn& :k&n sand
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER Gf a lieabie
` FROM TO DIAMETER THICKNESS MATERIAL
t' ft. a�ft. in. S +- p�C
Company Name
W^' �� 16.INNER CASING OR TUBING eotherntal closed too
2.Well Construction Permit#: V `�� ✓ o FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc) ft ft. in.
3.Well Use(cbeck well use): . ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_.Agricultural [DMunicipal/Public OC r1 t. 320 a in. ,®t Sch� Pvc—
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft in
IndustriaUCommercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: © ft• ap fL ,r Of`
Monitoring Recovery ft. ft. �
Injection Well: ft. ft
r-tAquifer Recharge Groundwater Remediation
_ Aquifer Storage and Recovery DSalinity Barrier19.SAND/GRAVEL PACK(if applicable)er FROM TO MATERIAL T EMPLACEMENT METHOD
Aquifer Test [1 Stormwater Drainage cpoft. J-3 fc *L o2 e_ J
Experimental Technology In Subsidence Control ft. I ft. J�R�I
Geothermal(Closed Loop) MTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rack a rain size,etc.)
_ Geothermal(Heatin Cooling Return) `Other(explain under#21 Remarks) ft. a ft e
4.Date Well(s)Completed: t�PJ"o�1 Well ID# ft. C\ ft d
u CA
5at.Well Location: ) ft I ft Q yarf 1
; „t
l ft. ft. fan C �
Facility/Owner Name Facility IDn(ifapplicable) O� ft. ft.
J ft 7J ft
Physical Address,Ci d Zip �j ft ft.
--low_ 1p sr.''�—� -1 6 —1 f,�3�a.,� 21.REMARKS
County Parcel Identification No.(PIN) O��
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: IQCSSSiftg Dl
(ifwell field,one lat/loonng is sufficient) pb 22.Certification: " pWR SgCz•0
11
350
�� , l�D� NIL—�I. X W
s-a
6.Is(are)the well(s) ermanent or CITemporary Signature of C fied Well Con ctor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: MYes or 0N0 with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 421 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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL LN'STRUCTIONS
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjeretu(example-3@200"and 2@1001 construction to the following:
10.Static water level below top of casing: ! (ft.) Division of Water Resources,Information Processing Unit,
If Hater level is above casing,use"+" 1617 Mail.Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: LP (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
. .. ((�� ! ` above, also submit one copy of this form within 30 days of completion of well
.Well construction method �(11.�_. KG��AW\� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 9 Method of test: ( _ 24c. For Water SuDnly&Infection Wells: In addition to sending the form to
e e rr the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ! Amount: P completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016