GW1-2021-06588_Well Construction - GW1_20211029

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name f`A-Q'y,cLIN FROM ft TO ft. DESCRIPTION
NC Well Contra for Certification Number
�,t 1 �� •,n1 0 �rti10t 15.OUTER CASING for multi-cased:wells OR.LINER':if a lica6le
/'�Q �/.VI �� I f�„l, FROM TO DIAMETER THICKNESS MATERIAL
II k mil.! r 1, "' �i'3 ft. ft. in.
Company Name
I�^ 16.INNER CASING ORTUBING eothermalclosed-loo
2.Well Construction Permit#: o _CJ' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. 0 ft. in. k
3.Well Use(check well use): ft. ft. in. t!
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:)Agricultural f__ Municipal/Public R, in.
—I Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft. ft. in•
IndustriaUCommercial Residential Water Supply(shared) 1 is GROUT
M Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: R. 20 ft. Vr
CI Monitoring (..!Recovery ft. ft.
Injection Well:
J Aquifer Recharge QGroundwater Remediation
19.1SAND%GRAVEL PACK';if a i licable _?
Aquifer Storage and Recovery DSalinity Barrier FROM TO I MATEJUAL EMPLACEMENT METHOD
L. Aquifer Test OStormwater Drainage ft. ft.
_J Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary),"
FROM TO DESCRIPTION color,hardness,soil/rack type,grain size,etc.)
Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) © ft ft
4.Date Well(s)Completed: Well ID# ft. © ft. �n
Q % t3 jl ft. %� ,/
Sa.Well Location: n ' �J vv •qq rJ'r-
0 - ,"b 3 1)ft. 2 ft. I 1
Facility/Owner Na Facility ID#(if applicable) CC)% <> Z D ft. O
Jag 601AI-1 Put le- AJ 6-
Physical Address,City,and Zip
ft. ft.
C A,n�.jj g e� 21.REMARKS
County f C/ C/ Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/loon�g in Ito +L
s sufficient) ^ 22.Certification:
`TD 13J1LfI N D'T�3q,72 f
W
6.Is(are)the well(s) Permanent or OTemporary a of Certified Well Contractor Date
By signing this farm,I hereby certify that the well(.e)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or [DNo with 15A NCAC 02C.0/00 or 15A NCAC 02C.0200 Well Consiruction Standards and that a -
lfihir is a repair,fill out known well conrtructi Information and explain the nature of the copy 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 site details or well
construction,only 1 G �needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
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 ifeli ferent(example-3@200'/and 2@100') construction to the following:
10.Static water level below top of casing: ( � (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 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
�� L ,, �/ above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: �� J�T�� 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) Method of test: j,< 24c.For Water Supply&Injection Wells: In addition to sending the form to
�-y the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection typed J LD Amount:,Z, 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