GW1-2021-00317_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
c 1
y N `� �. 14.WATER ZONES
Well Contractor Name"
FROM TO DESCRIPTION
Ut ova.-/ y'T �ftt
ft.
NC Well Contractor Certification Number - 15.OUTER CASING for multi-cased wells OR LINER(if a licable
\n,``�\'�j� � 1 \\1 FROM TO DIAMETER THICKNESS MATERIAL
V V 1 \ ��,IIIJJJ �J }` f[. ft. in. �;e_t 1 w
Company Name JLl`'l
16.INNER CASING OR TUBING eotherntai closed-too
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_.Agricultural [DMunicipal/Public ft. ft. in. , w�
Geothermal(Heating/Cooling Supply) Pesidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) t8.GROUT
Irri ation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. oft.
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
_ Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ao ft. ft ,�.
Experimental Technology �ISubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
_ Geothermal(Heating/Cooling Return) IOther(explain under#21 Remarks) r�'1 ft a ft
4.Date Well(s)Completed: �a' 3-cw We(]ID# lJ ft. : EqOWVASA r-U-1—
ft.
ft. ft.
Sa.Well Location:
ft. ft. C)i(CJIX� W
Facilit3#bwner Niam�e\�,� Facility ID##((ifapplicable) C'ND ft• � ft. �ffah C-cE Y-CLVgf
Physical Address,City,and Zip
r p 21.REMARKS
County\�A1 ii Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) °t
22.Certification:
ttrree//�� a°� w� I C
6.Is(are)the well(s)�/µt-ermanent or Temporary Signature of C ified Well Co❑ etor Date
T By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EJYes orYo with 15A NCAC 01C.0100 or 15A NCAC 01C.0100 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-I 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: �'T (N 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@2 0'and 2@100� construction to the following:
10.Static water level below top of casing: t (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
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: V1construction 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
13a.Yield(gpm) Method of test: Dy�QVlm 24c. For Water Supply&Iniection Wells: In addition to sending the form to
1 ( the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:AAJ� Amount: -'1 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