GW1-2021-06569_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: �(
•�r 14.WATER ZONES '
Well Contractor Narke FROM TO DESCRIPTION
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a licabte)
FROM TO DIAMETER THICKNESS MAT�E�R7IAL
t 1 ft. I a N ft. I in. 5Ch (,) P V
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: y y� C�o -tu::Inc O FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Counh',State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREENFROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. 01 ft. A in- tW u pyc�
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Itri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Oft. et. bentov�
❑Monitoring ❑Recovery
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 ❑StormwaterDrainage ot0 ft. 31 ft. 1 r
❑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,grain size,etc.)
p J ft. ac ft. s 0
4.Date Well(s)Completed:`�'� U 2 Well ID# ft. % ft. h
5a.Well Location: ft. a ft. In
6,11 Lis Ic\,hner al ft. ft. rU
Facility/ wner Name Facility[D#(if applicable) I.�ft. ft. (-%
a 3 �NwA 0y,� 6. Nev�r1-er C-ro.�e �� a�3 ft. ft.
Physical Address,City,and Zip ft. ft.
51.1�Y I�D'��� " U U 7 -I�� pf y�I 21.REMARKS I t e '
Count Parcel Identification No.(PIN) S� - 0�' (�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees.
(if well field,one lat/long is sufficient) 22.Certification'
35 , a3lak� N � g I.J 12 W
9/L 2
6.Is(are)the well(s): (ermanent or ❑Temporary Signature of Ce fled Well Contract Date
Bev signing this form,I hereby certif},that the wet/(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 00 15A NCAC 02C.0100 or ISA 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: 1 (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')
11 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"+"
24b.For Injection Wells: Copy to DW , Underground Injection Control (IUC)
11.Borehole diameter: ` (in.) `� s�." RProgram, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ` �T� 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) 1D Method of test: VPermit Program, 1611 MSC,Raleigh,NC 27699-1611
t
13b.Disinfection type:1� N Amount: ��
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018