GW1-2021-04561_Well Construction - GW1_20210429

WELL CONSTRUCTIONA CORDTGW-I)- _ -For-Intemal-Use-Only: -
I.A1-ofntractor Informmation:
��SO► " PbOs/'i 2���/ 14.WATER ZONES,
Well Contractor Name FROM TO DESCRIPTION
it. it. M
13 )"
NC Well Contractor Ceer�rtification Number 15.OUTER CASING for multi-cased wells OR I INER t a ►ieabte
G {�`1 1)O �� O. FROM TO DIAMETER THICKNESS MATERIAL
U`� ( ft. ft. in.
Company Name
40 16.INNER CASING OR TUBING(geothermal closed-ioo _
2.Well Construction Permit#: FROM I TO I DIAMETER TRICKINESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) ft. L ft. In.
3.Well Use(check well use): et. et. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SUE THICKNESS MATERIAL
Agricultural [] unicipal/Public et. ft. in
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
IndustriaL/Commercial Residential Water Supply(shared) IS.GROUT
nlrrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: tt. Q %
Monitoring EIRecovery
Injection Well:
Aquifer Recharge Groundwater Remediation
19.;SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage B• h•
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach addittonal sheets if necessary)
Geothermal(Heating/CoolingReturn Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,sollfrock type,grain size,etc
L C>ft. d ft.
4.Date Well(s)Completed: 1 Well ID# ft. S(U ft. G l
Sa.Well Location: O ft ft.
EDh�Q S1 QauN ft. ft.
Facility/OwnerName y� Facility ID#(if applicable) ft. fL
L61 wmoVVS %. m mtN ft. ft.
Physical Address,City,and Zip
W 21.REMARKS
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County Parcel Identification No.(PIN)
021
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: APR 2 9 2
(if well field,one lat/long is sufficient) 22.Cc dill adon I
i inforlration Processing nil
N W DWR Sedd,
6.Is(are)the well(s)dpermanent or Temporary Signa of`Cert7ficTW­cllVtractdY, Dat
By signing this form,1 hereby certify that the ive/l(s)was(were)con rutted' accordance
7.Is this a repair to an existing well: E]Yes or �io xdth 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Consiniction Stand and that a
lfthis is a repair,fill out known well construction 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 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 wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: k60 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'mud 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: 1 (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: Mxr construction to the following: a
(Le.auger,rotary,cable,direct push,etc.)-�
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: Jam, 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: ICl/ 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 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