GW1-2021-00062_Well Construction - GW1_20211109

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
14.WATER ZONES -
FROM TO DBSCREMON
Well Conht�actonr Name
-6� t
NC Welt Conbuator Certifiaatioa Number
M 017iSR190eft'
YG or m sea wells R LINIiR uanbie
I_ _L/ • J �,�w FROM DIAMBTER UUCKNM MATERIAL
YlTtf �I 4�0►S �'l/ • ft. in.
Company Name
1G INNER CASING OR TUBING closW400
2.Well Constriction (�Permit A 1 ' D /. . FROM TO DIAME MIt I TMCMCW MATERIAL
Liar all applicable well construction permits(i e.UJV,County,State,Variance,etc.) ft ft. I im
3.Well Use(check well use): ft. ft. la
Water Supply Well: 17.SCREEN: ._
FROM TO DIAMETER SLOT SIB TIUCKNES4 MATERIAL
Agricultural EgMlmicipal/Public O fit fL in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fr, ft, im
_ Industrial/Commercial Residential Water Supply(shared) I&GROUT
Irri 'on FROM TO -MATERIAL EMPLACEMENTMEMOD&AMOUNT
Non-Water Supply Well:
Monitoring Recovery fL ft.
Injection Well: �
ft. 10e)fL
_ Aquifer RechargeGroundwater Remediation
.19;SAND/GRANEI,RACK f. Bmble :La
_ Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMIM MMOD
Aquifer Test [3Stomrwater Drainage ft. ft. t t
Experimental Technology OSubsidence Control .
Geothermal(Closed Loop) Tracer ?0:DRILi]IVG LOG attachaddidanal shaft E
Geothermal atin Coolie Return Other lain under#21 Remarks) FROM TO DESCRIPTYON color lmrdn soahork ere
ft. M ed
y
4.Date Well(s)Completed: /0-4-11 Well ID# 7 ft'
5a.Well Location: ft" ft. K
Facility/Owner Name Facility ID#(if applicable) ft' ft'
/ ft. ft.
Physical Address.City,and Zip Z�Z ft.
G .Z=Lip( NZ 1 31 REMAR)i.4. • -
County Parcel Identification No:(PIN) I h
5b.Latitude and longitude in degrees(minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) q 22.Ce do
1
6.Kam)the well(s)Goermaneut or Temporary 19_a of Certified Well r Dare
�� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is,dds a repair to an existing well: DYes or Ell< with 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If ihls is a repair,fell out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair ender#21 remarks section or on the back ofthis form.
23.Site diagram or additional well details:
$.For Geoprobe/DPT or' -Loop Geothermal Well,having the same You may use the back of this page to provide additional well site details or well
construction,only 1 dW-1 is`needed. Indicate TOTAL NUMBER of wells construction details..You may also attach additional pages if necessary.
drilled: S_UBMiTTAL INSTRUCTIONS
9. a well depth below land surface: J 00 00 24a.For AB Wells: Submit this form within 30 days of completion of well
For' Itlple wells list all depths if different(example-3@200'and 2@100) construction to the following: ,
10.Static water level below top of casings 2 9, (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. 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Q D above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: /� construction to the following:
(Le.augey rotary.cable,direct push,etc-)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2769-0-1636
13a.Yield(gpm) Method of test J/Qw.n ZOw: 44c.For Water Snnuiv&In ruction Welhc In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount /�dtsrt E[� completion of wolf constttrotioti tO the county health department of the county
where constructed.
Form GW-1 NoRh Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016