GW1-2021-04215_Well Construction - GW1_20210415

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use only:
1'.Well Contractor Information:
r7 14.WATER ZONES
Well Contractor Name V - �1'' " t / !�� 1 FROM TO DESCRIPTION
Xa7 q� � ft. r b ft. S
ft. ft.
NC Well Contractor Certification Number A r 1� 1 J 2021 15.OUTER CASING for muld-cased'welis OR LINER if Usable
�1 y- ii.. �/►/� '/' M TO DIAMETER "TMCKNESSS MATERIAL
�1 I��UV�� W 1!J� \IYM. •�,YTiI�\�.fn {itr� RIP In. I O V
1.01 r
Company Name (� `° '~t;011
[� -f 1 ^1 1:6.;[1VNER CA G OR TUBING eothetmal closed-loop)
2.Well Construction Permit#: W OJ J 1 /) �`O A 1 FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(I e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Weil: 17.SCREEN
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
Agricultural unicipal/Public iL ft. in
Geothermal(Heating/Cooling Supply) GjResidcutial Water Supply(single) ft. fL in
Industrial/Commercial [3Residential Water Supply(shared) 18.GROUT
hTi ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: it 0 tt. h�0 1/G ;
Monitoring Recovery ft. ft.
Injection Well: fL fL
Aquifer Recharge Groundwater Remediation
19.SANDIGRAVEL PACK.Of a livable
Aquifer Storage and Recovery Salinity Barrier mom TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DR11LLING LOG attaefi additional sheets If noes
Geothermal(HeatingiCooling Return) ' . Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hirdnem soiltrock type,gritin siza,etc.
p '^ ft. a ft. -to l SO
4.Date Well(s)Completed: 3,a[ -°1I Well ID# a fL 5 ft. .Sa n
Sa.Well LocationPA;I(
5 ft' 2 v v it Y�N r6G
e A K • ft. ft.
Facility ID#(if applicable) ft• ft.
5do /w rA to Se ed J. ft. ft.
Physical Address,City,and Zip ft. ft.
Wa (<c /77J'a3 7q0 q 21.REMARK6
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: t gr
-N W 71
*4
6.Is(are)the well(s) Permanent or Temporary Signa&of Certified Well Contractor Date
By signing this form,I hereby certify that the nell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or [3No ,vith 15.4 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 and explain the nature of the copy of this record has been provided to'the well owner.
repair under#21 remarks section or on lire 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 t GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �� (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi,(ferent(example-3@200'and 1@100� construction to the following:
I
10.5tatic 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 Injection 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: r'D io r/ construction to the following:
(Le.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 276994636
13a.Yield(gpm) �s Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) 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