GW1-2021-05245_Well Construction - GW1_20210503

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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ontractorNameROM TO DESCRIPTION
Well
MAXA X 3
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Z � IrI��r►"atton Pr���..sin�Unit �� ft. 3p rt.
NC Well Contractor Certification Number 1 I Ior►
"'� // �y�5£� � 15.OUTER CASING for multi-cased wells OR LINER ii a licable
U v e We` 9) 4 �e-H 2Y✓�L le FROM TO DIAMETER THICKNESS MATERIAL
ft. Y d It. in.
Company Name
A V q�� ^ 0 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: P�f D ` pL FROM To I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Coun),,State,Variance,etc.) rt. ft in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
� FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
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Agricultural Municipal/Public o ft. ?PQ IL in. t\ In pile
_.J Geothcrmal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
lrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C ft. �r ft. I�Qn/oh• { burt
-'Monitoring t RRecovery
Injection Well:
ft. ft.
_ Aquifer Recharge OGroundwater Remediation
�,�, 19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT TROD
Aquifer Test OStormwater Drainage 1 ft. It. in
ve 4,2re
l Experimental Technology D Subsidence Control ft. ft.
1 Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) I
FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
4.Date Well(s)Completed: �- 9-j Well ID# ft- 30! it ap
5a.Well Location: 3 p ft. o It.
D ft. 3 f,-
Qtahe oi►�S /t'
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
16 S 4 ik, 3 d Ote4 LI/e N/- 1-7$ 3 � ft. ft.
Physical Address,City,and Zip ft. ft.
AA21.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.C 'fication:
3S:G sw� N 17 f W
6.Is(are)the well(-) Permanent or OTemporary Si tune of Certified Well ntractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair loan existing well: E]Yes or oNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fill out known well construction information an 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 GW-1 is 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 UO (fr•) 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'a[n°d 2@1001 construction to the following:
10.Static water level below top of casing: .7 (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 Iniection 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: 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) ct i/ Method of test: a' 24c.For Water Supply&Iniection Wells: In addition to sending the form to
l the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Cn 1b r i h Q Amount:^) 1 a U l• 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 Resource's Revised 2-22-2016

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