GW1-2021-07032_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information•
1 oar �II� �r -
14.WATER ZONES
Well Contractor Nami FROM TO DESCRIPTION
- � sft. '
NC Well Contractor Certification Number
15.OUTER CASING for'mulli-cased wells OR LINER(ita licablc
FROM % DIAMETER THICKNESS MATERIAL
l , u t ft. ��fL in. I c, ►_ -�
Company Name ►
16.INNER CASING OR TUBING keo m thcral closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER 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 Well: 17.SCREEN,
FROM TO DIAMETER SLOT SIZE TH,IC`K_NESS MATERIAL
:.)Agricultural MunicipaUPublic 30t. ft. /� in.
-I Geothermal(Heating/Cooling Supply) 1 esidential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
_ hYi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. tt. D�r. _
Monitoring ORecovery 5c) Wz
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a Ilcable
Aquifer Storage and Recovery [])Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:)Aquifer Test
IStonnwater Drainage a rift. l�^U ft. µ ��
_.Experimental Technology FnISubsidence Control vft. ft. i�
_Geothermal(Closed Loop) r.IITracer 20.DRILL]NG LOG attach additional sheets If n&6ssa
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,eta)
ft. a ft. 'tD 't
4.Date Well(s)Completed: "1 Well ID# ft. ft.
Sa.Well Location: ft' ft.
Facility/Owner Name Facility ID#(if applicable) t. C) ft.
0 yb 1
Phy cal Address,City,and Zip
(�1 L 'V'J _,y 21.REMARKS E)
County 11}�r ILLY Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: PlfOfln3tn PIQCe
�'
(if well field,once tat/long is sufficient) f'�p �1 22.Certification
6.Is(are)the well(s)il_permanent or OTemporary Signature ofCertf ed Well Con for Date
"l 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: EIYes or o with 15A 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 nd 6plain 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-I 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: (ft-) 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 2@100') construction to the following:
10.Static water level below top of casing: au (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 Iniection Wells: In addition to sending the form to the address in 24a
a v� above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: mVta � �v1 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) Method of test: 24c.For Water Supply&Injection 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.
1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016