GW1-2021-00324_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: _I
LV c W 1 �w e VCR 14.WATER ZONES,
Well Contractor Natne FROM TO DESCRIPTION J
tQ G� ' f ft. Z ft. -Gf n ea rl d YOi
!1 q ft. ft. u n s�
NC Well Contractor Certification Number `
f� t y1 . IS.OUTER CASING(for'multi'ca'sed Wells)ORL�I/N'E.jR�`ifJa--licablc-
lw1 Ld t 11 D 1-1. ` ��r r t 1 1 ft.FROM Toft. DIAMETER in. T #qo MATE`RIA,L
Company Name T L V V
A 16.INNER CASING OR TUBIN cothernial closed-loop)
2.Well Construction Permit#: S r b o�y b I 00 142 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. Ulr,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
1Z SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public g l ft. ft. tn• t 0 r 9L Gil q(J 19 VG
Geothermal(Heating/Cooling Supply) g
esidential Water Supply(single) LI it. 5 2-ft- n. Z � o pVG
Industrial/Commercial Residential Water Supply(shared) r `/
181GROUT.
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring Recovery ft. ft. 13f n4 -f e
Injection Well:
ft. ft. d Ulf 1�0.v�r
_ Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a licablc 7
Aquifer Storage and Recovery EISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD )
Aquifer Test ®IStonnwater Drainage 2 ft. �a ft. a Sa (Jl{V ] t/1 fT
_':Experimental Technology ®I Subsidence Control ft. ft.
Geothermal(Closed Loop) OITracer 20.DRILLING LOG(attach additional sheets if necessa` `
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
_i Geothermal(Heating/Cooling Return) 010ther(explain under#21 Remarks) D ft. ft. S p
4.Date Well(s)Completed: 3-3 -2O We11 ID# ft' /� it' s n c
5a.Well Locjation: /l ft. a ft. f an w lc e a
k -e H'pyv�e (GIs o1 ft
Facility/Owner Name Facility ID#(if applicable) 33 ft. 1 ft. G(A Ci 1 a
d 1 J 1 ft. /-1 ft. -FC1 11 J L.
L6-�' to '_ f'nr.,1'n S'-} 6 Q C!-t "I J
Physical Address,City,and Zip n ft. ft.
V�& rrt o b �"0' 6,6014 21.REMARKS
4 a
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
<3s52 te• N '79'0 N3/fig W
6.Is(are)the well(s)Opermanent or 1ITemporary Signature of C tfied Well Con ctor'. Date
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: DYes or
Ifthis is a repair,fill out known well construction information' No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
nd explain the nature ofthe copy ofthis record has been provided fo 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: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiereni(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: ' Oil (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: a (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
y�n I, /�' above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: "1 J r 07L Gt d construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
i
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 25, Method of test: J0 Lk r4 le 1$1 24c.For Water Supply&Iniection Wells: In addition to sending the form to
L the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: R CI Amount: t C-Vl P completion of well construction to the county health department of the county
he. constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016