GW1-2021-06570_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Law U ' l I AAA —Ir 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name I
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER(if a livable
FROM TO DIAMETER TffiCKNESS MATERIAL
SC
ft in. �Q
Company Name
`�,` 16.INNER CASING OR TUBING eotherntal closed-too
2.Well Construction Permit#: U 'R OoLLo FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e. 01C,County,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 [DMunicipaUPublic t. 2,-1 fL a in. •�1 S v�
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. J ft. in. Lf
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. o ft. � - r _
n
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if a livable
:)Aquifer Storage and Recovery [3ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage t�aL 3111 ft. a
:)Experimental Technology OSubsidence Control ft. ft.
BGeothermal(Closed Loop) r.1ITracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ]Other(explain under#21 Remarks) FROM1 To DESCRIPTION(color,hardness,sail/rock type,grain size,eta)
O ft. ft. S l7\
4.Date Well(s)Completed: t7c - Well ID# ft. g ft.
Sa.Well Location:
ft. ' ft. 0,�1 1
Maly ,r. w0 a5 ft. �tG ft. a� G �
Facility/Own ame Facility ID#(if applicable) a$ ft. 3�01 3 ft. IWA
w o N 3 ft. ft, - .�
Physical Address,City,and lip t I` g ��(� 5 I v ft ft.
So
M DSQ� l f\Vi�l1 m9 a "/� 13 21.REMARKS
County —L I Parcel Identification No (PIN) l f 1,
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: � �
process.Ing Unit
(if well field,one IaUlong is sufficient) 22.Certification: p\f R Secllon
N 930 32 . 1 3a W ,� r a
6.Is(are)the well(s) Permanent or ®ITemporary Signature of Ce red Well Contrac r Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [)Yes or Adexplain
No with 15ANCACO2C.0100or15ANCACO2C.0200 Well Consmrction Standards and that a
If this is a repair,fill out known well construction information 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: �7 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 / (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3( 200'and 2@100� construction to the following:
10.Static water level below top of casing: t 0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use..'1. 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (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
12.Well construction method: MU6, ROA'0'
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: EWMJ9(T 24c. For Water Supply&Infection Wells: In addition to sending the form to
I the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: I`t 1 rl Amount: 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