GW1-2021-07042_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: P
1.Well Contractor Information: 1
Law \ •l �t I 1 V, � 3 y 14.WATER ZONES l i
Well
Contractor
.Na a /F�ROOM TO DESCRIPTION
pC
D ft
ft. ft. I
NC Well Contractor Certification Number 1 15.OUTER CASING for multi-cased wells OR LINER if u lieable
FROM TO DIAMETER THIICKNESS/-� MAT(EER`I'AL
in. JLh kA V t'v�
Company Name n
C�D .4i- r� �/�1 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: Ft e t _ M-1 I S� 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. it. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
I
_ Agricultural [)Municipal/Public ac7ft, 3 ft, rn• C71� YC,
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) Dft. ft. in.
- Industrial/Commercial DResidential Water Supply(shared) 18,GROUT
-Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D
ft. Oft. t1 'boo�
Monitoring ORecovery
3 �JD�bs i�
Injection Well:
:)Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
_ Aquifer Storage and RecoveryISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage C>ft. ft. a —Dour
:)Experimental Technology r.1ISubsidence Control ft, ft.
Geothermal(Closed Loop) FnITracer 20.DRILLING LOG(attach additibnal sheets if necessary)
Geothermal(Heating/Cooling Return) (explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock a rain size etc
_:
ft. ft. �Olt
4.Date Well(s)Completed 1 Well ID# ft. ft.
Gt-
5a. eelll� J
Location:
� , ft- 2� ft. +DL _W-I r G L�
lAA 1�'`�VkTW �1 ft. 33 ft. WVS�- h
iv
Facility/Owner
Nam`eaFacility ID#(if applicable) y� ft. ft.
Ph Address,City,and Zip ft. ft.
O
I JV I l po' oa I 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
k0 —W A
1
6.Is(are)the well(s) Permanent or OTemporary Signature ofCe 'red Well Con ctor Date \\
il IUI
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or 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 informationOndexplain the nature of the copy of this record has been provided la 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-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: 33 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@2000'and 2 a 100') construction to the following:
10.Static water level below top of casing: v (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: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
ry� above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1 1,�1� Y� L 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: Urn ( _ 24c.For Water Supply&Iniectii n Wells: In addition to sending the form to
1 i the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: `� Amount: completion of well construction tol 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