GW1-2021-07495_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Informations:
A i �P :14:WATERZONES
G�
Well Contractor Name FROM TO DESCRIPTION
� f 7 _ it. ft.
f4 ft
NC Well Contractor Certification Number I15.OUTERCiASIN -(for mulH cased wills OR'LINER'if a'`licsble
/ -^j I FROM TOc� DIAMETER TaffiCIQVESS MATERIAL
1 t ft. I !� ft. in.
Company N e �
16:INNER'CASINGOR:TUBING. cokhecmalclosed-loo' 'i =
2.Well Construction Permit#: FROM I To I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) % ft. in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. g, in.
Geothermal(Heating/Cooling Supply) P:esidential Water Supply(single) fL ft. in.
Industrial/Commercial Residential Water Supply(shared)
:18:GROUI; _
_.Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: t57 ft. -!2'U %
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
i19:SAND/GRAVEL SACK rf.a`'livable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD '
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) QlTracer 20:DRiLIiING LOG`(aHach additional sheets it neces"s
Geothermal(Heating/Cooling Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/rock a in size,etc.
0 ft. v ft. 61R S�n�
4.Date Well(s)Completed: Well ID# ft- 3rf© ft.
5a.Well Location: ft. ft.
1q,C, ��� 2ic e� ft. ft
Facility/Owner Name j ,pFacilittyy ID#(ifaapppli le) ft. ft.
&�.A
ft.
ft.
Physical Ad ress,City,and Zip
ft. ft. ir
r 9Id t.,.e l'1 all V'S l�7� 21.REMARI{s- - - (�
County Parcel Identification No.(PIN)
202,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �P ct,i iUIV
(if well field one laUlong is sufficient) 22.Certification• 11"rORMATIr1AI P
• RnrFccrmr Mir
W
1 f 2.3 2/
6.is(are)the well(s)�ermanent or OTemporary Signature of Certified Well Contractor 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: QYes or QNo with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
If this is a repair,fdl out known well constrnction information and 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.
filled' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(a)200'and 2Q100� construction to the following:
10.Static water level below top of casing: `�U ' (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276"-1617
11.Borehole diameter: lD (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: 4,y /1 B �/ 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:�. �. � 24c.For Water Supply&Injection 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: 'L A/ Amount: U 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