GW1-2021-07036_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:Ln�I VI � l 'yAzXA 0 1 1,
14.WATER ZONES '
Well ContractorName FROM TO DESCRIPTION
NC Well Contrjkctor Certification Number
',r 15.OUTER CASING for multi-cased'Wells OR LINER if a licablc
/C �'0( FROM TO DIAMETER THICKNESS MATERIAL
J 1 ` l! t fL ft. r „ in. q 1 —e �/
Company Name ( m —1 ) Y
16.INNER CASING OR TUBING
eothcral closed-loop)
2.Well Construction Permit#: �� �`r` C 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): fit. fit. in.
Water Supply Well: 17.SCREEN.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:)Agricultural [3Municipal/Public fit. fit. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fit. fit. in.
Industrial/Commercial RResidential Water Supply(shared) 18.GROUT. ! '
_ h1i ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: /t'�tt. a 0 1c .-� _ l 1
Monitoring ORecovery
Injection Well:
ft. ft.
_ Aquifer Recharge E3 Groundwater Remediation 19.SAND/GRANGE PACK if a licablc
Aquifer Storage and Recovery ]Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test r.IIStonnwater Drainage
Experimental Technology lSubsidence Control
Geothermal(Closed Loop) MITracer 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.)
C� D AU ft. ft. D 1 (
4.Date Well(s)Completed: O Well ID# Q
ft. ft. !1 `a
5a.Well Location: Cl ft. ft 3� . l'ctC
Facility/Owner Name Facility ID#(if applicable)
$O lu ( W(05 bvla l C;hankw LRAM �e ft. ft.
P I sical Addrress,,'Ciity,and Zip — J ft. ft. °
�'JLT la 051) 40Uf1(/�I33 21.REMARI{S `
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
• i,pracessln
(ifwell field,one lat/long is sufficient) 22.Certification: I' DWR
II t`byea N 93' . Ct I I W � _
g'ag� I�
6.Is(are)the well(s)a� e r
ermanent or Temporary Signature of Ced Well Contf
tot Date
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: QIYes 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 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-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: O (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiereni(example-3@20 'and 2@100') construction to the following:
10.Static water level below top of casing: I (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: 10 (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: uf� � , construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
sion 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: m ) 24c.For Water Supply& Iniection Wells: In addition to sending the form to
i the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well constructioh 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