GW1-2021-07045_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD (GW-1) -�-N For Internal Use Only:
1.Well Contractor Information: ~
L6 ` ( Y 14,WATER ZONES t !
Well Contractor
FROM TO DESCRIPTION
R�nNam
liVt eft. ert 3 ft. ukl� s4KM
ft. � ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
- i ft. 2-p ft. '�- in. S(Jj Q 1 Y vc-
CompanyName
16.INNER CASING OR TUBING cothcrmal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft 0 ft. ii L in. S(h q U PVC
3.Well Use(check well use): 1 ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:!)Agricultural Agricultural IDMunicipal/Public 2-C't. aft. t in.
I Q a! �1 S�H(�d
I/
O �--
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
In7 ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. Z ft. en r11 te 31 2 SV l u S
In Monitoring EIRecovery ft. ft. O u
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a Iicablc
Aquifer Storage and Recovery ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_,Aquifer Test �IStormwater Drainage Z v ft. 2 ft. Z''s y( PD Yr
i Experimental Technology rMISubsidence Control ft. ft.
BGeothermal(Closed Loop) JTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)Ell (explain under#21 Remarks) © ft. ft. S )
O
4.Date Well(s)Completed: �b Well ID# / ft ft. 11di 11G •ee
5aa..Well Location: 1 ft, ft. n'-WA i Tf Gt/Q
%fkw 81 ft. 21 ft. 'OoIrse s !1
Facility/Owner-(Name I ,n Facility ID#(if applicable) ft. l ft.
TOn L AQ61 �t�
.y "v
Ph sicaI Address,City,and Zip ft. ft.
1� III 2` O O � 21.REMARKS () +
J`
County Parcel Identification
No
No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35° I1, ROZ- N ��° �� y W �✓, l� Za iq
6.Is(are)the well(s) Permanent or OTemporary Signature of W fied Well Con etor Date
llllll"```������°°°°°° %,dexplain
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: EI
Yes orNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information the nature of the copy of this record has been provided io 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: COE—" A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: I Cal (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"'+"n 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
r_,,A �rnw above, also submit one copy ofjthis form within 30 days of completion of well
12.Well construction method:M`�Y UMA construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) " Method of test: '(y (�Q 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: Amount: 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 Resou ices Revised 2-22-2016