GW1-2021-07966_Well Construction - GW1_20211122

tl Print Form.
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well
Contractor Information:
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 3--i O ft. ?✓.•""'�ft. O ,pry1
�<D&V - P�_
NC Well Contractor Certification Number 15'OUTER CASING'(for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Company Name CD ft. /, o tt / G in. l 7 a I PV G
1 , 16r INNER CASING OR TUBING`'eo'thermal dosed400
2.Well Construction Permit#: I O �/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Coun)4 State,Variance,etc.) ft ft in.
3.Well Use(check well use): k. ft. in.
Water Supply Well: 17.`SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft. ft.
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
Nlnigation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. a� ft.
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge [IGroundwater Remediation _
19:`SAND/6RAVELTACK-'if a'"licable
Aquifer Storage and Recovery [ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) E3Tracer 20'DRILLING`LOG(Attach additional-sheets if necessary),
Geothermal(Heating/CoolingReturn) `) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soiUmck a Ala size etc)
ft. ft
^j
4.Date Well(s)Completed:j a, I Well ID# ft' fL (_.^
Sa.Well Location: ft' D ft' t �r-Ot 1L-v
\roe— V e•�t'�S � 1rt�i n�� ft. ft.
59
Facility/Owner
^Na—me nFacility ID#(if applicable) ft. ft. @� e
� � ft. ft @� A
Physical Address,City,and Zip l r\•G a- 13 S CQ ft. fL
21.RENfARKS
County Parcel Identification No.(PIN)
wP SECTION
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: !NFeRHAMm PmrFIt i Ugh
(if well field,one lat/long is sufficient) 22•Ce
N W /� '� 7-� �
6.Is(are)the well(s) . ermanent or OTemporary Signature of Certified Well Contractor 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: ®Yes or with ISA 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 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.
drilled: L SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00D construction to the following:
10.Static water level below top of casing: ls1 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+•' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Iabove,also submit one copy of this form within 30 days of completion of well
12.Well construction method: I r r 1 ` construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: Q 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ' o Method of test: 1 24c.For Water Supply&Iniection 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: 1-} 1 � Amount: �t� L completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of environmental Quality-Division of Water Resources Revised 2-22-2016