GW1-2021-04550_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
tift 14.WATER ZONES
Well Contractor Name y � FROM TO DESCRIPTION
� i O ft. 0 fft.' 2 9 ft. ft. CA I
NC Well Contractor Certi6cat" n Number APR t� .OUTER CASING for multi-cased wells OR LINER'Of-applicable)
�/Ae�t ���' Cp Prr1CG�S1�;! OM TO DIAMETER THICKNESS MATERIAL
1 ►1WI-'1:3�it� SBl rrOlr ft. ft. in. C
Company Name �,N(Z -
G W a H 9 0 0 Q 16,INNER CASING OR TUBING eothernial closed,loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Coun)4 State,Variance,etc.) ft• it. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural /Pu unicipalblic ft. ft. in.
Geothermal(Heating/Cooling Supply) 1YRmid,,tial Water Supply(single) R, n, in,
1ndustriai/Commercial OResidential Water Supply(shared) 18.GROUT
lrrl ati0n FROM I TO MATERIAL. EMPLACEMENT METHOD R AMOUNT
Non-Water Supply Well: O fi' 26 Ira
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL.PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20,DRII I INC I OG atfaeh additional sheets if necessa" ,-
s
Geothermal eatin Coolin Return) -Other(explain under#21 Remarks FROM ft. TO DESCRIPTION(color,bardn soiUrock in etc.)
4.Date Well(s)Completed: `— 2� Well ID# ft. ft.
5a.Well Location:
DA III J Caro/I l ft. ft.
Facility/Owner Name Facility ID#(if applicable) R• ft
q 6 JS 111 w o o ll id IQo%Ig hl /U��
Physical Address,City,and Zip
bkt U79'/G63786) 21:REMARKs
County Parcel Identification No.(PIN)
5b.Latltude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22 Ce 'teation:
N W
6.Is(are)the well(s) ermanent or Temporary Si cure of ertified el 6nt"actor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or &No with 15A NCAC 01C.0100 or 15,4 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 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 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details, You may also attach additional pages if necessary.
drilled: I t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ` S� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: A) 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: rc construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,tnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: n 1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) v Method of test: Ifs �b%J 24c.For Water SuDDIv&Infection 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