GW1-2021-07030_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Informatio
11 r 14.WATER ZONES is
Well Contractor Narhe FROM TO DESCRIPTION
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if u licable
FROM TO DIAMETER THICKNESS MATERIAL
1 ft. 3 ft. of in. QX/
Company Name , ,
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. UIC,County, tote, 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 [)Municipal/Public ft. ft. O� in •p1t
:,,)Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in. `t' V
Industrial/Commercial (Residential Water Supply(shared) 18.GROUT'
_ hYi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. t. V_ r
_ Monitoring Recovery ft. ft. bS eQej
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery []]Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0StonnwaterDrainage ft. ft. A-
Experimental Technology r-IISubsidence 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 a rain size,etc.)
o ft. ft. "'�
4.Date Well(s)Completed: D� Well ID# ft. ft.
Sa.Well Location:
ft. I ft.
NkAhXft. ft.
Facility/Owner N ne Facility ID4(if applicable) A ft. ft. r
l J�3� B ���C7I 1.1 DV�I n PC ft. ft.
Physical Address,City,and Zi ft'
b/1lil,�/)h 21.REM ARK,
County (tlil Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ''nn{{ fir»
(ifwell(fiield,one((lat/long is sufficient) 6 22.Certil'Ic'tdlq dl'3tiOn Preee'Saing Unit
N D� Aq,Lee W MR,ke n
--) a8
6.Is(are)the well(s) rimanent or OTemporary St ature ofCeVled Well Contra i• Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
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7.Is this a repair to an existing well: E)Yes 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 information a explain the nature of the copy of this 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: (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: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use•'+I"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
�y above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: ' v`
.e.auger,rota construction to the following:
(�r g rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1\ 1636 Mail Service Center,Raleigh,NC 27699-1636
Vm 13a.Yield(gpm) Method of test: I 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: Y 1 Amount: I 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
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