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HomeMy WebLinkAboutGW1-2021-07363_Well Construction - GW1_20210921 WELL CONSTRUCTION RECORD G N For Internal Use Only: 1.Well Contractor� Inform lion:�6Lyl� ox` 14.;WA'jER`zANE3'. Well Contractor ffNam c FROM TO DESCRIPTION �l 2rs5% ff r . ft. ;F rP tCev��pA tt. ff. NC Well Contractor Certification N bar �(^3� 1 t 1S.Ut1ThRCASIN for multi-cbsedve is'UR LWER;tta llcable, 1 ,,Gr FROM TO DIAMF.I•F.R TIIICKNESIS MATE�RIIAAL V t-(tn -N l ft. r 1 S D K�1 V L, Company Name 4 n ( r �r/ 16:INNER CASING Ott TUBING: eotherfste)'lbscd=log 2.Well Construction Permit#• J r I / FROM TO DIAMFTFR THICKNNxS MATERIAL List all applicable well consnnctiot permits(i.e.UIC,Coun'%Sm/e,Variance,etc.) ft. ft. In. 3.Well Use(check well use): n' ft. In. Water Supply Well: 17c'SCREEN FROM I TO DIAMETER SLOT 817,E TIIICKNFSS MATERIAL Agricultural �MunicipaUPublic ft. ft. IIn• Geothermal(Heating/Cooling Supply) OKesidential Water Supply(single) n• ft. !In. Industrial/Commercial OResidentiai Water Supply(shared) 18.GRgUT hTi ation FROM TO MATERIAL EMTLACEWn METHOD&AMOUNT Non-Water Supply Well: 0 ft. ft. � D .;Monitoring ORecovery ft. ft. Injection Well: ft. ft. Aquifer Recharge Groundwater Remediation 193AND/GRAVELPACK Ifs llcable Aquifer Storage and Recovery Salinity Barrier FROM TO MATFRIAL EMPLACEMENT METHOD Aquifer Test C)Stormwater Drainage ft• if. Experimental Technology Subsidence Control ft. ft. Geothermal(Closed Loop) Tracer 7 20::DRILLXNG LOG•.attach.adillHonlls4cets lf:uecessii Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM 5t , To ft D cturnoN color hardnecr solUrorkt e min stu err.Jf4.Date Well(s)Completed:���)Weli ID# p JC tt. Ll b © ,I D 5a.We Location: I Pt. ft. Facility/Owncr Name Facility ID#(ifapplicable Physical Ad Tess,C• ,end J II ryl C d pdU I 21..RElYIARKS County Parcel Identification No.(PIN) 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (ifwell field,one lattlong is sufficient) 22.Certification: 6.Is(are)the well(s)&K-rmonent or 13Temporary Signature ofCeitified Well Contractor Date By signing flits Jbiwi,I hereby cer16 that the well(s)was(were)constructed in accordance 7.Is this a repair to an existing well: QYes or WO with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a b'thls is a repair,)?Il otif kio;iw well constrneuon h formation and explain ilte nanati3 ojthe copy oj/hfr record has been provided to the well owner. repair under 1121 r•emorks section or on the back of this jorm. 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: ''L (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well For multiple wells/It/all depths 1fdder ent(erample-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, ,i/wrAe•Jerel is above casing,use"•1" 1617 Mall Service, enter,Raleigh,NC 27699-1617 r 11.Borehole diameter: (in.) 24b.For Inlection Wells: In addition tojsending the form to the address in 24a above,also subunit one copy of this form'within 30 days of completion of well 12.Well construction method: f b a-✓ V- construction to the following: (i:e.auger,rotary,cable,direct push,etc.) Division 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: -4 r 24c.For Water Supply&Iniection Wells: In addition to sending the form to -1 the address(es) above, also submit one copy of this form within 30 days of 13b.Disinfection type: O r I Amount: &Z.G 5 completion of well construction'I to the county health department of the county where constructed. Form GW-I North Caroline Department of Environmental Quality-Division of Water ResourcI s Revised 2-22-2016 N