GW1-2021-06568_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
LD 'yl 14.WATER ZONES
Well Contractor Name u FROM TO DESCRIPTION
Qs W� OQ 1 ft. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased'welis)OR LINER(if a 6cable)
�`f�`^�, FROM TO DIAMETER THICKNESS MA`ERA AL
l"+ }1 fL '1 ft. in. h (3 ?V
Company Name e 16.INNER CASING OR TUBING(eothermal closed-loop)
2.Well Construction Permit#: " (-Q\- �7J: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,CountT 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 ft. An ft. in. OQ SLV)kAO Pv
❑Geothermal(Heating/Cooling Supply) Aesidential Water Supply(single) ft. ft. 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: tO ft. 02� ft. �� 50 b
❑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 Oft. 3D �� +-
42
❑Experimental Technology ❑Subsidence Control ft. ft. i'�
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil rock t),pe,grain sim,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) D ft. I ft. p
4.Date Well(s)Completed: U Z Well ID# ft. !6 ft. S O rx !n
5a.Well Location: C/ft. I ft. Or U O _
r^� ,�J�L ft. 1 ft. anCICAJ
id
Fj itacci�lity/O rear Name y�1 , S1 �Facility ID#(if applicable)�D I ft. p 5-ft- U ✓) S!7 h
Y \L u.I.M�C b COY yo KP� 1 w�5�(� i O N( ft. ft. If`
Physical Address,City,and Zip J ft. ft.
G \ __ ✓��^ ` 12 Qn 21.REMARKS County Parcel Identification No.(PIN)
Processing nl
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
:torn^afbn
(if wellll field,one lat/long is sufficient) Q 22.Certification: (n v
N -7 D t O� W C 1/,, c r W -�D -zl
6.Is(are)the well(s): Permanent or ❑Temporary Signature ofCertibTed Well Contract6fDate
txplain
Ay signing thisform,/hereby certifi that the wel!(s)was(were)constructed in accordance with
7.Is this a repair to an existing well• ❑
Yes or0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 We!!Construction Standards and that a copy
1fthis is a repair,fill out known well construction information a 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: �C) (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),
If Static water level below top of casing: (fL) Information Processing Unit, 161,7 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:�� ��l 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(gpm) 7 Method of test:
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
` V
13b.Disinfection type: ` Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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