GW1-2021-04573_Well Construction - GW1_20210429

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WELL CONSTRUCTION-RECORD-(GW4)-- For-Irrterne Use-Only:—_ _
1.Well Contractor Informatiion:
1615 ph PC b 1 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
� ft. 0 ft.
It
[t. ft.
NC Well Contractor Certification Number 15.OUTER CASING for ruuitl=Cos s OR LINER`if A livable
S/1Mr+rt C-ir Jay OO�e ej� CO. o To J S ft. DIA11fETER TatTHICKNESSMATERIAL
tt. in
Company Name /If INNER CASING OR TUBING eothermal ciosed4eo
2.Well Construction Permit#: �o DIAMETER
I THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,CounV.State, Variance,etc) R• fL in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM I TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural [] unicipal/Public ft. I ft.
Geothermal(Heating/Cooling Supply) ffRsideritial Water Supply(single) fL ft iw
IndustriaUCommercial OResidential Water Supply(shared) 18.GROUT
lrrl ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
ft. 0 ft. ,L n� h' V
Monitoring E3Recovery ft. ft. P
Injection Well: ft. ft
Aquifer Recharge []Groundwater Remediation 19.SAND/GRAVEL PACK its lii able
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING.LOG attach additional sheets ifneeessa
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION color karanes solUrock 1n stmeto
f I O ft, ft.
4.Date Well(s)Completed: ! 7-�r Well ID# tr p fa q e G
5a.Well Location: 30 R' ILD ft.
Tin auirtj
ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
La( ,&Wool Jr �llacon, 17 1551 ft. ft a� g� 10
Physical Address,City,and Zip
W G r f L n 21.REMARKS
County Parcel Identification No.(PIN)
n Processing
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �5e?'4tull
(if well field,one lat/long is sufficient) 22.Certification: (AN R
N w ;L t
6.Is(are)the wells) Permanent or OTemporary
Signature drCcrtified Well 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 W(No with 15A NCAC 02C.0100 or 15A NCAC 01C.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
constructiory,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I �� it-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if djf Trent(example-3®200'and 2@1001 constriction to the following:
10.Static water level below top of casing: 4 a (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use^+' 1617 Mall 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
1 above, also submit one copy of this form within 30 days of completion of well
r'12.Well construction method: OT ar 51 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 27699-1636
Blow13a.Yield(gpm) Method of test: 1 o w _ 24c.For Water SuDDiv&Iniecdon Wells: In addition to sending the form to
' I�. 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