GW1-2021-07041_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We[Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
rt. 31 ft. t
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'tveIts)OR LINER(if a `licablc
�� I J FROM TO DIAMETER THICKNESS MATERIAL
1 ft. ft. in.
Company Name GT
16.INNER CASING OR TUBING 'eolherntal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C County,State, Variance,etc) ft. rt. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN.,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_.Agricultural DMunicipal/Public ft. 31 ft. in. �� S„ _PVC.,_;Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in 11
Industrial/Commercial rJlResidential Water Supply(shared)
18:GROUT.`
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1 ft. r l r-a ft.
:-)Monitoring DRecovety ft. oC l ft.
Injection Well: ft. ft.
_ Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
: Aquifer Test r.1IStonnwater Drainage tK)ft. / ft. ' �Lr
Experimental TechnologyISubsidence Control ft. ft.
B
Geothermal(Closed Loop) C]ITracer 20.DRILLING LOG(attach'additionilshcets"'if nti&ssa )`
Geothermal(Heating/Cooling ReFROM TO ft. DESCRIPTION color,hardness,soil/rock e, rain size,etc)
Return) I(Other(explain under#21 Remarks) ft. !
4.Date Well(s)Completed:1� �(`) "1 Well ID# ft. it.
5a.Well Location: ft. f ft.
`��� 'n1 ft. ft.
Facility/O n� Facility ID#(if applicable) ft. ft.
c ,,
01(A(P(
Physical Address,City,and Zip ft. ft.
21.REMARK
County Parcel Identification No.(PIN) r Cf.F�r;�C.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
40'3 �J e N t
W � � •
6.Is(are)the well(s)Opermanent or OTemporary Signature of Certifie ell Contractor Date
By signing this for ,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing wellIYes or No with 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction it formation explain the nature of the copy of this record has been provided to the well owner.
repair under 421 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-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: L/� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierew(example-3@2004'aan+d,2@100') construction to the following:
y 10.Static water level below top of casing: \ (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: l fJ (in.) 24b.For Iniection 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: ma 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
i
13a.Yield(gpm)to Method of test: Dom 0*10A 24c.For Water Supply&Iniection Wells: In addition to sending the form to
1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 4' 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