GW1-2021-04552_Well Construction - GW1_20210429

.Print Form.
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor I formation: q '
REG14.WATER ZONES
We 1 Con FROM TO DESCRIPTION
tractor Name
�3 6`� AP R ti 9 2021 20 ft IV I ft. 6
v 7 v ft Z� ft
NC Well Contractor Certification Number e;flly PI����SIn�
��„ 1�,�c•' r� C 0(1 15.OUTER CASING for multi cased wellsER THICIINESs OR LINER if a Gcable
FROM TO DIAMET MATERIAL
(� � ft ft 6 in v
Co pany Name s
I/�I^I / (� Q /� 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: G V"_ c 1 6�/ I�O',/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Coun)4 State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft ft in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
i Agricultural []Municipal/Public 0 ft. ft in.
i Geothermal(Heating/Cooling Supply) ffResidential Water Supply(single) ft. ft in,
J Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: U ft Z- ft.-31 I
Monitoring DD Recovery ft. ft
Injection Well:
ft ft.
J Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
J Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL. EMPLACEMENT METHOD
I Aquifer Test OStormwater Drainage ft ft.
J Experimental Technology Subsidence Control ft ft
J Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets if necessary)
_I Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiurock tyM grain size,etc
ft- 6 ft rl x
4.Date Well(s)Completed: / �J Well ID# 6 f fr S Q
5a.Well Location: ft ft
64
aft n(M^.SMP` ft ft
Facilliit l/Owner Name�N/" Facility ID#(if applicable) ft ft
2 �33 WInd�m4 6R4 kEl 1AIRU ktsf ft ft
Physical Address,City,and Zip ft. ft
WA lot 21.REMARKS nnpp
County Parcel Identification No.(PIN) QGF e
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W �G�
6.Is(are)the well(s)fyPermanent or Temporary Si tore o ertified We Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or [No with 15A NCAC 02C.0100 or I5A 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: j SUBMITTAL INSTRUCTIONS
?n
9.Total well depth below land surface: Jui) (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: —30 (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 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: � 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) l O Method of test: hvi 24c.For Water Supply&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:ilng Amount: j 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