GW1-2021-07790_Well Construction - GW1_20211102

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well ntractor Information:
44.WATER ZONES
7 7 ..
Well Contractor Name FROM TO DESCRIPTION
�d V It 171 ft r ra l'
—�-b ft ft
NC Well Contractor Certification Number
�15 OUTER CASING for'uiotti4aitid*ells`OR'TJNER''If a''-cable
D0 ys (�eII Dr;III�Q FROM TO DIAMETER THICIOVESS MATERIAL
Compan Name I ft.
3 ft. m. ,CC/ v
9 '7 ��p "16`INNER"CASINGORTUBING eotherinal closseed0-loo
2.Well Construction Permit#: L t FROM TO" DIAMETER TMCKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,Courtq;State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft ft. In.
Water Supply Well: i7 SCREEN -
_. r
el—
FROM I TO DIAMETER SLOTSIZE Tn[CRNESS MATERIAL
Agricultural 0yunicipal/Pubfic fL ft in.
Geothermal(Heating/Cooling Supply) E_ Residential Water Supply(single)
C-
ft. ft in.
Industrial/Commercial EIResidential Water Supply(shared)
:;IS.GROUT _
Irri aeon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: G ft. 'Z0 ft agn
to C p)U
moeJ
Monitoring Recovery ft. ft 1'
Injection Well:
Aquifer Recharge OGToundwater Remediation ft' ft.
19:SAND/GRASVEI;PACK fa, icable
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
I. Aquifer Test oStormwater Drainage ft. ft.
Experimental Technology (Subsidence Control ft. ft
F Geothermal(Closed Loop) (3Tracer 20 DRILLING LOG(attach add itional'sheets if necessi
Geothermal(Heating/Cooling Return) i Other(explain under#21 Remarks) I
FROM TO DESCRIPTION color,hardn soiffrock in size,etc.)
1+ a ft. ! 0 ft. v U P
4.Date Well(s)CompletedcQ7 1 Z I Well ID# (31 ft 400 ft. Fey
hl'
5a.Well Location: ft. ft.
11J�Tam G . Mmuo!n ft. ft
Facility/Owner Name Facility ID#(if applicable) ft ft. �>
17S 1 Dick PhiN;as Rd Wei ITPFfPfsan ZSCg4 ft ft
Physical Address,City,and Zip t ft. ft. n
IWO
AcAe— l 5 271 021 21:REMARKS. .:. tll
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 22.Certifica' n:
N W XIL-
6.Is(are)the well(s)dermanent or OTemporary Signature ofCcrtified tractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0 Yes or S)4 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 information and explain the nature ofthe 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 GW4 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: L1VO (B) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100� construction to the following
10.Static water level below top of casing: DU` (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use'; 1617 Mail Service Center,Raleigh,NC 27699-1617
il.Borehole diameter: fir (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: -S 1�
(� above, also submit one copy of this form within 30 days of completion of well
Q G1�y 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
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13a.Yield(gpm)2 Method of test: r• 110 24c.For Water SuDDIv&Injection Wells: In addition to sending the form to
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the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: C1 07, 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