GW1-2021-00322_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Welll `]1 Contractor Information:
t
I�nforma�tion:1
_Dtm � `�1 � mk Tr 14.WATER ZONES
Well Contractor Ame FROM TO DESCRIPTION
ft,
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER(if a Hcable
FROM TO DIAMETER THICKNESS M(�ATERIAL
Company Name _l lD ft. � in. SC_j)(A(D PVC_
16.INNER CASING OR TUBING eotherntal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County.State, Variance,etc.)
3.Well Use(check well use): in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
M Agricultural Municipal/Public Rom. ��
_ ft, fin. `� � �� Pv
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
III'i ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Oft. ft.
Monitoring Recovery ft. ft. [?kr ~Sb I
Injection Well: ft. ft. Y
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
_ Aquifer Storage and Recovery MISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStonnwater Drainage Oft. O ft, *-� �ra V"
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) rJITracer 20.DRILLING LOG(attach additional sheets if necessa )
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
_ Geothermal(Heating/Cooling Return) lOther(explain under#21 Remarks) ft. a ft.
l
4.Date Well(s)Completed:,a 3b(D Well ID# ft. ft.
5YvIr\
ell Locatio ft. ft.
h"v1l t U QO ft. ft. n 1
F11acnnilityl/.�Ow`ner-Name Facility ID#(ifapplicablc) ft. JL/2, ft.
Physical Address,City,and Zip ���aaalll��L��k ft. ft. lr l 7 n
('I 1 �\L/O( �Q 21.REMARKS , '•` i 9,s'
County Parcel Identification No.(PIN) (11 4' r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient)
^�? 0
1 N 0 q / 22.Certification:
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6.Is(are)the well(s) Permanent or OTemporary Signature of C fied Well Con or Date
3y signing this form,1 hereby certfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or No with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information n 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: SUBMITTAL INSTRUCTIONS
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 ifd8erent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: (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 Infection 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:��� d ,�X construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,jUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: ) 24c.For Water Suoniv&Iniech'on 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: Amount: 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