GW1-2021-07034_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
L CA Inl 1 V rJ✓ 14.WATER ZONES _.
FROM TO DESCRIPTION
Well Contractor ame
d` _ ft. �( ft• �� Gt nU d' Yi7l Ve
NC Well Contractor Certification Number y� 15.OUTER CASING for multi-cased wells OR LINER if a Iicabie
W i I 1 I oy S well l 1 ►Jy1 Il ie� FROM ft TO^^ ft DIAMETER to TffiCKNESS MATERIAL
Company Name l of a SC H N V PVG
I ' 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. VIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. it. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:)Agricultural OMunicipal/Public ft. ft. in t a��O 5G I Iqd p�
Geothermal(Heating/Cooling Supply) residential Water Supply(single) in.
Industrial/Commercial OResidential Water Supply(shared)
18,GROUT._
71 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. ft. 19 eritow' 3( 2 v l I u
/
Monitoring Recovery ft. ft. 1�`1'
CI
Injection Well: �e �U
ft. ft. QUY Yj7IV
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK lfa licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL` EMPLACEMENT METHOD
_- Aquifer Test
IStonnwater Drainage ff 31•} ft. ��U/( DU lr
Experimental Technology niSubsidence Control
_, Geothermal(Closed Loop) QlTracer 20.DRILLING LOG(attach additional sheets if neeessa
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
D ft. of ft. O so)'
ff
4.Date Well(s)Completed: (O't� Well M# ft. f ft- re t f IS h Gf M 4
5a.Well Location: 9 ft. 2 3 ft. - 4 rl C W
SU nd,l CveeK Land co a 3 ft. $ ft. fin n d-cievtvel
Facility/Owner Name Facility ID#(if applicable) ft
le) r�O ft. . et C4 h t'.
& o SW c c-I1 CLxxP+S4YjMA)t 4D� 3 ��Lrd mia A ft. ft.
Physical Address,City,and Zip ft. ft. >
Cum 6 e la n o49S 0 6 71'3 z1.REMARKS
County Parcel Identification No.(PIN) A
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Uva
(ifwell field,one latt//llong�is sufficient) 22.Certification: prGCe
?q�.Sy /b'7 � r 1`.$O(�',3�+OP1 rli0tl
f N 7� gD . F3o
6.Is(are)the wells) Permanent or rIITemporary Signature of C fied Well Cozpractor Date
By signing this form,1 hereby certify that the we/l(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or 6o 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 oflhis 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 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: J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: I (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 Injection Wells: In addition to sending the form to the address in 24a
l above, also submit one copy ofi this form within 30 days of completion of well
12.Well construction method tn9 I�l G( f'0 +Y 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: D U IYI►71,lI A 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: T Amount: (- completion of well constructiori to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016