GW1-2021-00326_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Informatio11n: �(
LeL Y V\ \/V)`l 1�` v 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
1 ft. rluft. Coarse n 54nel
ft. ft.
NC� /Well Contractor Certification Number 1 IS.OUTER CASING for multi-cased wells OR LINER(if a licable
FROM TO DIAMETER TffiCKNESS MATERIAL
{ ` IL "1 ft in. ` PVC
Company Name 16.INNER CASING OR TUBING eotherntA closed-loop)
2.Well Construction Permit#: 1 J 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 MATE
:-)Agricultural [DMunicipal/Public ft t oS O 1 a �` `'-fo
Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. a Q fL a
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.S.4NDlGRAVEL PACK(if ap livable
_ Aquifer Storage and Recovery OSalinity Barrier FROM TO 1 MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage aC)fL 1.,ft.
Experimental Technology OSubsidence Control ft. W ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type, rain size,etc.)
O ft. p ft. 0 O '
4.Date Well(s)Completed: �aa "a Well ID# ft. t:, ft s e4 n
c 16L
5a.Well Location: ft. ft. �-q e U
A 41
ft a -w h 1'4 e c/a
Facility/Owner Name Facility ID#(if ap/p livable)4 ft. '7I f 0 ft. u J1 5 A I1 —C I Ll
Physical Address,City,and Zip fL ft
C11� Coarse
21.REMARKS DECCounty Parcel Identification No.(PIN) EC 2 0 2021
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ••r,Ar'F^'r•'
(if well field,one lat/long is sufficient) ?;.a Y,v^ Y
t' 22.Certi'fication: �•..�r "'�ra'ilr"'e'*M�'re, io`(If•I'.
3`{ ) 5R rSQ1 N _-19 15"1 30� r r liTM7,:ii� t :r; •.�..,;,ii:'
W (icy 4t �—as—Q
6.Is(are)the well(s) Permanent or IITemporary Signature of Certi d Well Contracto Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or io with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
ffthis is a repair, Ill out known well construction information and explain the nature ojthe 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: P (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd fferent(example-3@200'and 2@I00� construction to the following:
10.Static water level below top of casing: A) 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: I(S (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Cnt u,� RO 1 above, also submit one copy of this form within 30 days of completion of well
12.Well construction method:J1wi`1W rV construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) O Method of test: OPT "I C 24c. For Water Sunaly&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: 1 Amount: I completion of well construction!'to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Envirotunental Quality-Division of Water Resources Revised 2-22-2016