GW1-2021-06564_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: -
,'`k � _.k 14.WATER ZONES
Well Contractor Na (�l r FROM TO DESCRIPTION
\t\'\ % V fL )I 1 fLcArm se',
rd
NC Well Contractor Certification Number (1p
�� 1p slav`C 15.OUTER CASING(for multi-cased wells)OR LINER(if a 6cable
FROM TO DIAMETER THICKNESS MATERIAL
yV\ •S W��� 1� '` _` +-I ft. 1C2 ft. � in. SChq �(
Company Name
�` � 16.INNER CASING OR TUBING(geothermal closed-1 ICKN S
2.Well Construction Permit#: l FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Counht 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 0gft. • 1 ft. in. `a xf _A(:) VL.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) Oft. ft. in.
❑Industrial/Commercial Residential Water Supply(shared) 18.GROUT
❑hrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 00 ft. BCfNA-0n; ci'n )Dl
❑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 a0ft. ,t�")ft. � r,
❑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) W-7,7
TO DESCRIPTION(color,hardness,soil/rock type, rain sin,etc.)
ft.
4.Date Well(s)Completed: Well ID# 9 ft. s ` Q
5�a.Well Location: MOMI' 1171 a t5 - 3 o ft. I&C K, G A
Facility/Owner Name Facility ID#(if applicable) 0 ft. - ft. YR ku
Vft b Df_ J_\a h 11,dt'. N'C. A N-7 qr. ft. sei\d clAY Al I�
Physical Address,City,and Zip O ft. // ft. YA
d3 ®>.••1Q 21.REMARKS
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:
2A i593 J38 N '')8i,9gxt_tD W
. �
6.Is(are)the well(s): Kpiermanent or ❑Temporary Signature of CtIfied Well Co tractor Date
Xd
By signing thisform,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing we►l: ❑Yes orNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy'If this is a repair,fill out known well construction informationxplain 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-I 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 I (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')
10.Static water level below top of casing: j (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 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: �Lva 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
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: U 1 I
13b.Disinfection type: Amount: jA4
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018