GW1-2021-07796_Well Construction - GW1_20211102

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well C n actor I tin: f
Well Contract a FROM TO jsDESCRIPTION
�
ft. ft
NC Well Contractor Certification Number 15"0,UTERCASING,far:mnitt-casedwells A_ RLIlVER':(if a hcable s :..
M o r a n.Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
gft. ft 61/8 in sdr21 JPVC
Company Name .'
r
n16i1NNER-.CA G;OR;TUBING e•othermal'closedloo
2.Well Construction Permit#: V FROM I To I DIAMETER THICKNESS MATERIAL
List all applicable well constntction permits(i.e.UIC, ounry,State,Variance,etc) +fll
ft in•
3.Well Use(check well use): ft in.
Water Supply Well ,1VSGREEN e
pP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft fL in.
❑Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) i8 GROUT ff
❑Irri ation ❑Wells>100,000 GPD FROM TO• MATERIAL" EMPLACEMENT METHOD&AMOUNT.,
Non-Water Supply Well.- 0 ft. 20 ft bentonite poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVELEAC3C, tfa""liea6le -
[I Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer -.1VDRn1JNG"1:0 G(itfikhidditi 6 ditiiiiiifif,dnecess
❑Geothermal(Heating/Cooling Return) ❑O.ther(explain under#21 Remarks) FROM TO DESCRIPTION(co or,h dness,soil/rock a ram size,etc-)
ft. fL
4.Date Well(s)Completedq
s i Well ID# t s ft. , ft C
5a.Well Location:
arks VA ft. ft
F cility/Owner Name acili ID#(if applicable)
N. ft
Physical Address,,City,and Zip Q ft. ft t1 2
' us
C4rB�5"�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient) (� 4Ceafion:
6.Is(are)the well(s): *Permanent or ❑Temporary Si e o Certified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 4?No 15A NCAC 02C.0100 or 15.4 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 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 construction info
construction,only I 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 INSTRUCTIONS
9.Total well depth below land surface: 2p© (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 1 a@100�
24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" '
6 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWI,CCPCUA
�j air pressure Permit Program, 1611 MSC,Raleigh,L NC 27699-1611
13a.Yield(gpm) L b Method of test:
�13b.Disinfection typ u,, Amount: �0 ,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018