GW1-2021-00325_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Lay\1 ' y\j 1 I � hyz� 14.WATER ZONES
Well Contractor Name FROM TO DESCRI ON
,n ft. ft. %� t YVAI-- .
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased:wclls OR LINER if a licable
`t FROM TO DIAMETER TffiCKNrrE/ISS MATERIAL
` t f ft. ft. in. (� q tD {!N►-
Company Name
16.1NNER CASING OR TUBINGcolhcrmal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well consbwction permits(i.e. VIC.County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. it. in.
Water Supply Well: 17.SCREEN.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_!Agricultural IDMunicipal/Public ft, ^1 ft. in.
:),Geothermal g pp(Heating/Cooling/Coolin Supply) esidential Water Supply(single) l in.
_ '-C
Industrial/Commerc al Y) residential Water Supply(shared) 18.GROUT. ft.
_ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O
Monitoring13Recoveiy
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL PACK(if-applicable) ,
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStonnwater Drainage A�ft. �� Y
Experimental Technology r.IISubsidence Control
Geothermal(Closed Loop) r.JITracer 20.DRILLING LOG. attach additional shecti if neccssa
In Geothermal(Heating/Cooling Return) ]Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
ft. ft. l
4.Date Well(s)Completed: o-12 DQ�11 ID# ft. ` I;k ft.
5a.Well Location: �j ft, ft.
�Q`l 1 n 1 \� err a ft. �1 1 ft. ko_n �1
Facility/Owner Name Facility ID#(ifapplicable) ft. Ali a� ft.
1
/ 1
mA Pb-b\e ft.
Physical Address,City,and Zip
21.REMARKS
County , �C• Parcel Identification No.(PIN)
1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `
C
ifwell field,one lat/lon sufficient ,-
g�is ) 22.Certification:
357 Q.. 319 N I w
6.Is(are)the well(s)�Ixpl✓ermanent or OTemporary Signature of C ified Well Co ctor Date
7� By signing this form,1 hereby certify iihat the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or [TNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constniction Standards and that a
Ifthis is a repair,fill out known well construction information ,explain the nature ofthe copy ofthis 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: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii erent(example-31200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lfwater 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
12.Well construction method: above, also submit one copy of this form within 30 days of completion of well
�Vc� �(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service;Center,Raleigh,NC 27699-1636
13a.Yield(gpm) C Method of test: 24c. For Water Supply&Iniection Wells: In addition to sending the form to
0 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction Ito 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