GW1-2021-07035_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
LAt I/1/I ky iF0 V61 J_K 14.WATER ZONES I
Well Contractor Nalne FROM TO DESCRIPTION
A 50 YAVe
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if a Ilcablc
f FROM TO DIAMETER THICKNESS MATERIAL
►�J 1 11 ,-hy s we t t �YI'111`n 4 _ ft. a 3 ft. in. SC H V yG
Company Name
16.INNER CASING OR TUBING "cothermal closed-loop)
2.Well Construction Permit#: l 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
_ Agricultural
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
t1gResidential
Municipal/Public f[, a.3 a 8 - ► 01b 5(_ti'i u VC,Geothermal(Heating/Cooling Supply) esidential Water Supply(single) f f in
._ Industrial/Commercial Water Supply(shared) 18.GROUT
Inn ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. D ft. n►i our 3i 2 /ISol b
Monitoring DRecovery ft. ft. u $ efAdeiglU
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
_I Aquifer Storage and Recovery (Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test
Experimental Technology I ft. ?
r.1ISubsidence Control
ft.
Geothermal(Closed Loop) ITracer 20,DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc.)
__,Geothermal(Heating/Cooling Retum)n GlOther(explain under#21 Remarks) O O ,1
4.Date Well(s)Completed: -� 1 ( Well ID# ft. ft �-edd I S�1 G/Gt -$ U n M ^1
5a.Well Location: t�_ ft. 01 ft. -}GI n GI u
�gn�y C✓eeKLur�Co 3 ft. 2g ft. Ian s t4h d- raVe
Faciu ,I1��
lity/Own rNamee �^ Facility lD#(ifapplicable) U
6/g Se 1 Coo 1"}' J+edma Pt t_o-�
Physical Address,City,and ZZ* ft- ft-
rn t°V�U n oy 9.5=53-s&5_ 21.REMARI{S
County Parcel Identification No.(PIN) OCT 9 1 2021
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,onne n/
e lat/lo sufficient)
ng is sucient) 22.Certification: Information Processing
37 0 SLe '/ l N r9 yti- Q G 2� c p��1�R.5eC1!On
U
6.Is(are)the well(s) Permanent or OTemporary Signature of ified Well Con factor 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: DYes or Pf_No 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 and explain the nature of the copy of this record has been provided lathe 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 GW-1 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 ifdierent(example-3@260'and 2@100') construction to the following:
10.Static 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 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: rn Ll� V U�41' construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSWELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
(
13a.Yield(gpm) 0 Method of test: u- 1 a 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: T Amount: , it completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016