GW1-2021-00069_Well Construction - GW1_20211109

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1. Ii Contractor Information:
14.WATER ZONES
We Contractor Name FROM I TO DESCRPCITON
C: � NO ft.
ft. ft.
NC Well Contractor Certification Number 15:ODTER CASING` rmatusasea we OR LINER it ncable)
� — -(p � I n �i �� FROM ft-
TO DIANI$TER�. THICKNESS MATERIAL
Company Name" V�VJ�J V(/ (� 9-r
16.INNER CASING OR TUBING finteothermral closedloo V
2.Well Construction Permit : FROM I TO I DIAMEM THICKNESS I MATERIAL
List all applicable►yell construction permits(i e.UIC.County,State,Variance,etc.) ft. m.
3.Well Use(check well use): ft• ft. t°
Water Supply Well: 17',SCREEN
Agricultural FROM TO DIAMETER SUWSIZE THICKNESS MATERIAL
M Pal/Public 0 ft• ft• in.
Geothermal(Heating/Cooling Supply) esid intial Water Supply(single)
ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18 GRovT
1. IIrI atinn FROM TO MATERIAL LACBMENr OD&AMOUAPf
Non-Water Supply Well: ft. ft
Monitoring ecoEery ft. ft.
Injection Well: ft ft.
K_jAquifer Recharge LDGroundwater Remediation !9 SAND/GRAVEL PACK rif cable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
_ Aquifer Test nStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft
Geothermal(Closed Loop) [3Tracer 20.-DRILLING LOG'(attach additional sheets if necessarld
Geothermal Heatin Co ligg Return) 00ther a lain under#21 Remarks FROM To DESCIUMON color,hardness,soll/mck fte,onin dze,ate
ft. ft
4.Date Well(s)Completed:�.�o'1 Well ED# ft• ft•
Sa.Well
L� L�oc a�tion• r �' ftfftt' fftt.
'
- Z02_1Facili ty/Own Facility ID# if liable) ft .
Physical/Address,City,and Zip ft• ft. ' o I nl P R
•Ee— S©(n 21.REMARHS]�, //
County Parcel Identification No.(PIN) �" �' 1 Iry C— r
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long issusuffiicieQt) /C7
n �j 22. cation: U
N �C—_l91 �5�'"1 � W
6.Is(are)the well(s) ,Permanent or 13Temporary Signature of Certified ell Contractor! Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: es or [3No 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 hiformation and explain the nature of the copy of this record has been provided to the well owner.
repair tmtder#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 I GWyI is needed. Indicate TOTAL NUMBER ofwelis construction details. You may also attach additional pages if necessary.
drilled: rR r_ Trc-rro
9.Total well depth below land surface: (fL) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths 1f different(example-3@ 0'and 2®l00') construction to the following:
10.Static water level below top of casing: A5- (ft.) Division of Water Resources,Information Processing Unit,
if water level is above easing,use + 1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter.—_(in.) 24b.For Injection Wells: In addition to sending the font to the address in 24a
12.Well construction metilod above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following
Division of Water Remur ms.Undergnnnnd Ir aag-n Control P—$ram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.YIeId(gpm) 10 Method of test: 42 tndU 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: r Amount: `6 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