GW1-2021-07151_Well Construction - GW1_20211006

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For Internal Use Only:
1.,W,efitractor Inff do
%r6
Well ,.:, . Name
317C
NC W Contractor Certification Number
!/ao DtJ A)i4 .
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. U/C, County, State, Variance, etc.)
3. Well Use (check well use):
tik� 6 2021
0
process09 u)
e,minctr.3to jAeCt1Or% 1a
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
DM 'cipa1/Public
Residential Water Supply (single)
Residential Water Supply (shared)
DRecovery
Groundwater Remediation
Salinity Barrier
DStormwater Drainage
DSubsidence Control
Tracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed:II
5a. W Location:
4410CSS -1 gatete..A
Facility/Owner Name
02-.9 IrJy'1Dir'e
Physical Address, City, and Zap
county
Well ID# -
Facility ID# (if applicable)
/V /
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
6. Is(are) the well(s) ermanent or OTemporary
7. is this a repair to an existing well: QYes or to
If this is a repair, fill out known well construction information and explain the nature office
repair under 121 remarlssection or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 30-5 (ft.)
For multiple wells list all depths If different (example-3Q200' grid 2@1e0')
10. Static water level below top of casing: 3/ (ft)
U water level Is above casing, use "+
r
11. Borehole diameter: 6 7f (in.)
12. Well construction method: a N . tO t
(Le. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) r' Method of test: hJ r )/
13b. Disinfection type: H . 1 I' . Amount: / 1 LS
GW1-2021-07151
14. WATER ZONES
FROM
TO
DES RIPTION
6a fL
SS ft
e
a°OU-230
s '/,, 6 •Po/t'!
t to '
i 6 fL
I. '4, 6 .nri
15 OUTER CASING (for multi -cased wells) OR LINER (rfap hcablee))
FROM
TO
OL
ICKNESS
MATERIAL
Y f ft.
j ft
'/-i'
SHO/1.1
vG
i& INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft
fL
in.
ft
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
fL
ft
irL
ft
ft
in.
18. GROUT
FROM
TO
ERiAL-
EMPLACEMENT METHOD & AMOUNT
O fL
ao f ft.
krattZ
T.Irrip Oltreg OUT
fL
fL
SAthi7
Tome G/Q -r
ft.
ft
19. SAND/GRAVEL PACK
(if applicable);..-
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft
ft
ft
ft
20. DRILLING
LUG (attach
additional sheets if necessary)
FROM
TO _ _
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
6 ft
S ft
B g
60 ti.
/to fL
eva )n
it0 ft.
190 ft
Rerk
no fL
3 ft
&Misr
lgS fL
3 8-5ftReS-
21. REMARKS
N0Ia a6a-
Toot Skvel,
/ 4.-
fw/t0'C Hok a.
_
signing this form, / hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the welt owner
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
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
construction to the following
Division of Water Resources, Underground injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Suppiv & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction' to the county health department of the county
where constructed.