GW1-2021-07044_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14,WATER ZONES FROM TO TO DESCRIPTION
Well Contractor Nant rt. 3D ft. i ^ !9 .ndl
NC Well Contractor Certification Number �� 15.OUTER CASING for multi-cased'.wells OR LINER(if a licable
f�1 FROM TO DIAMETER THICKNESS MATERIAL
J v v y \ ft. U ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I 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 THICKNESS MATERIAL
_;Agricultural [DMunicipal/Public aLp ft. ft. in. Jt�/1LA 0 P-vL
_)Geothermal(Heating/Cooling Supply) F2<esidential Water Supply(single) ft. ft. in.
_ Industrial/Commercial rIIResidential Water Supply(shared) -
18.GROUT.
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. t. bc
t
Monitoring Recovery ft. ft.
e—C mj�)
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19:SAND/GRAVEL PACK If applicable)
_; Aquifer Storage and Recovery EISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_ Aquifer TestI Stonnwater Drainage ft.
Experimental Technology QlSubsidence Control
Geothermal(Closed Loop) ITracer 20.DRILLING LOG(attach additional sheets if necessary)'
[:]Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type, rain size,etc.)
ft. ft.
4.Date Well(s)Completed:, Well ID# ft, ft.
5a.Well Location: ft. _—A-P
ft. -IrIrAl Host
_ �^� � ft. ft.
Facility/Owner AN•amel Facility ID#(if applicabl ft. ft.
hysical Address,City,and Zip ft. ft.
�t( f�12 'L 1 ��✓� 21.REMARKS Sr- ?. \�
County Parcel Identification No.(PIN) sty'{ c.•r����
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: T r�ti
(if well field,one lat/long is sufficient) 22.Certification
5° �0�3�y N ,�,16� W
6.Is(are)the well(s) Permanent or OITemporary Signature of C ified Well Co ctor; Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EIYes or PtNo with ISA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofdris 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-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: 3p (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi.(fereni(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: O (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
above, also submit one copy of;this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) r
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY
]WELLS ONLY: 1636 Mail Service''p Center,Raleigh,NC 27699-1636
13a.Yield(gpm) OCO Method of test: Nry-101M 24c.For Water Supply&Iniection Wells: In addition to sending the form to
1 "f 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016