GW1-2021-05281_Well Construction - GW1_20210601

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contrwwac''tfor Informs' n:
nnM 14 WATER ZONES ,,7 ,x;,.
Well Contractor Name FROM TO DESCRIPTION
3 JON ft ft. �
n p;��essir��J t & f, `[
NC Well C nhactor Certification bet j IuI17'aD0�� BCr00 45.,OUTER CASING for-multrcased wells)OKLIlVER,if i hceb7c
/ ,�• c-� FROM TO DIAMETER THICIfTiFSS MATERIAL
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Company Name
`/�' ',�l) ^/ J� / �._16.INNER°:CASING:OR�TUBING:. 'eothe�mshclosedlo'o"
2.Well Construction Permit#: U O�`� t� T FROM To DIAMETER THICKNESS - MATERIAL
List all applicable well construction permits(,.a.WC,County,State,Variance,etc.) ft. ft. I.
3.Well Use(check well use): ft' ft in
Water Supply Well: FROME TO DIAMETER SLOT SIZE THICKNESS i y MATERIAL
_ Agricultural E]Municipal/Public ft. ft in:
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft IMj
Industrial/Commercial Residential Water Supply(shared) s '
18iGROUT '
hri ati0n FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft e y(j L,_ pu-r S
Monitoring _,Recovery & ft
Injection Well:
Aquifer Recharge DGroundwater Remediation fL It.
-19..SAND/GRAVEL PACIt If a 'licable ,: =>
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage ft It.
_Experimental Technology Subsidence Control ft• &
Geothermal(Closed Loop) Tracer 20`DRILLING LOG ittacb additiouel,stieets'if iiit6sa _
Geothermal(Heating/Cooling Return) _Other(explain under#21 Remarks) FROM TO DESCRDMON color,hardness,soWrotk a eta
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4.Date Well(s)Completed: 4 Well ID# /6 ft a�sft Cd So / Q POT
Sa.Well Location: It. ft '
ft. fi
Facility/Owner Name Facility ID#(if applicable) ft ft
ft it
Physical A dress,City,and Zip ft ft
21;REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude to degrees/minutes/seconds or decimal degrees:
(if well field,one Iattlong is sufficient) 22.Ce lion:
3S37g y-� N �51, �� W �
6.Is(are)the well(s) rmanent or OTemporary Signature of Certified well Contractor Date
By signing this form,I hereby certo that the wells)way(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out/mown wit construction information and ''plain 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 thisform. 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 veils construction details. You may also attach additional pages if necessary.
drilled: �sj7 --77 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(different(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.
246.For Infection Wells: In addition to sending the form to the address in 24a
�t above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: r d a y construction to the following: t
(i.e.auger,rotary,cable,direct push,etc.)'
Division of Water Resources"Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: n� �! 1636 Mail Service`enter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water SuDDIv&Infection Wells: In addition to sending the form to
/f the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: Y Cam' Amount' C 1 completion of well construction to the county health department of the county
where constructed.
Fotm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016