GW1-2021-07478_Well Construction - GW1_20211116

i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1•Well Contractor Information:
VAT `JlQ"le 14.WATER ZONES
Well Contractir Name FROM TO I DESCRIPTION
y395-A ft ft. 3 P
NC Well Contractor Certification Numbs M OUTT R CASING for multi cased wells OR LINER d a Gcable
1 Well Dr'1 FROM 11 DIANW R TffiQINF�S MATERIAL
` o fL 'Soft. i ,( / `°-
Company Name
16.INNER CASING OR TUBING thermal dosed-too
2.Well Construction Permit#: ILI 89 53 FROM TO DIA ESTER Tffi3Q M MATERLAL
List aAaMlicable well construction permits(e"IIIC,Comity.State,Yamfanc--etc) JL B• in.
3.Well Use(checkwell use): s. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICHNF.SS MATT-1iLAL
❑Agricultural ❑Municipal/Pubhe R it is
❑Geothermal(Heating/Cooling Supply) Ulkesidential Water Supply(single)
It. it
❑lndustrial/Commercial ❑Residential Water Supply(shared) I.S.GROUT
Olnip,ation' ❑Wells>100,000 GPD FRORi TO MATERIAL EM'LACE6t!ENT METHOD&AMOUNT
Non-Water Supply Well: 0 n- ire Pokf
❑Monitoring ❑Recovery ft fL
Injection Well: tG ft.
❑Aquifer Recharge ❑Groundwater Remediation
PAC% d applicable)
OAQutfel Storage and Recovery ❑ 19.SAND/GRAVEL,Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage R• IL
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 10.DRILLING LOG attach additional sheets ifnec ssa
❑Geothermal eatin Coolie Retum ❑Other FROM TO DESCRn'1TON(color,hardens,son/roek sae,eta)
(H g/ g ) (explain tinder#21 Remarks)
d ft In fL D ic+
4.Date Well(s)Completed: , ' 'ell Well ID# y VIII & ! •}
Sa.Well Location: 114n A00 Cat•V i ce
J� -A /d!meta /1?rC/Uno� rt $ &anile
Facility/Owner Name Facility MY(ifapplicable) r�ll^• fL
I ail �'h►uv►dec R;dae L�ciwJe WE51' )etttfsa ft. ft.
Physical Address,City.and Zip TUC 22(o9y it n
r
Ash a Win_03 21.REMARKS j
County Parcel Identification No.(Ply V `r L
021
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(rf well field,one IatRong is sufficient)
Jr_1,5UIV
22 Cer Gtticatioa: VTORMATION.PROCESSING UNI-
N W op
6.Is ar'e thewell s ^�r21( ) (). ®1'ermaIIent or ❑Temporary Signature o "fled Well Coetractor. Date
By signing thisform.Ihereby—*A-that thexwiffis)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 29o- 1 SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has beenprovided to the well owner"
repair under#11 remarks section or on the back of thisform.
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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCITONS
9.Total well depth below land surface: &e> D Submit this GW-1 within 30 days of well completion
For multiple wells list all depths ifdifjerod(example-3Q200'and 2@100) ( ) ys p per the following:
10.Static water level below top of casing: y� ( 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing use"+ ) Information Processing Unit,1611 MSC,Raleigh,NC 27699-1617
11.Borehole diameter r1'4 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
i
12.Well construction method: 24c.For Water Supply and Open Loop Geothermal Return Wells:Copy to the
(i.e anger,rotary,came direct push etc") county environmental health department of the county where installed
TOR WATER SUPPLY WELLS ONLY: f
24d.For Water Wells producing over 100.000 GPD:Copy to DWR,CCPCUA
? h!n ermit Program,l611 MSC,Ralei gh,NC 27699-1611
13a_Yield(gpm) 3 Method of test: �f P
13b.Disinfection type: K 1 N Amount: 8 OZ
,Q Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource's Revised 6-6-2018