GW1-2021-00327_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
c c t
L ix VV`+ ' \ V C.1 �Y 14.WATER ZONES
Well Contractor N e FROM TO DESCRIPTION
71 ft. 440
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for muItkasedi".wells OR LINER if a lieable
JAI "11"(-' V�S �/Pf�* .0Y 1 '1 1 h$ FROM TO DIAMETER Tm(n,& MATE�R`IAg�L
�/ e Y \ +1 ft. 3 to ft. 9L in. Sc 1i H V r Y L/
Company Name
16.INNER CASING OR TUBING m'eotheral closed-loop)
2.Well Construction Permit#: 4 2.S I?O}C e C d ani y FROM TO 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. it. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_:Agricultural IDMunicipal/Public 4:�ft. ft. r1 in. 1�I 70
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. et of
__ in.
Industrial/Commercial Residential Water Supply(shared) 18;GROUT.
h-ri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
ft. o ft. &Ahz 014Y A>^r^ylr
Monitoring DRecovery
Injection Well: �9
? A d l e
ft. ft.
_ Aquifer Recharge Groundwater Remediation J
19.SAND/GRAVEL PACK if a' lieable
Aquifer Storage and Recovery EISalinity Barrier FROM TO MATERIALA EMPLACEMENT METHOD
+,Aquifer Test IStonnwater Drainage ft. ft. OS Jo, Ck1 V �1 f,
Experimental Technology E]ISubsidence Control
Geothermal(Closed Loop) (Tracer 20.DRILLING LOG(attach additional sheets if n&essar
__I Geothermal(Heating/Cooling Return) i(Other(explain under#21 Remarks) FROM ft. ft.
DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
_ TO o $©1
4.Date Well(s)Completed: -7-2 2-10 Well ID# ft. ft. A n
5a.Well Location: ft. 1 ft. Cj n G lCA
L c,twt& 19 i eve d� ft. 2 / ft. f Ct fi -U h l e L(
Facility/Owner Name Facility ID#(if applicable) 34,
N w41 ft. Cali rS e 1i n sa A
S50 DID Fwf3+' A IRa e Fo>d IV 2i3�6 ft. I W ft. �/17
Physical Address,City,and Zip
Vk6V.` 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in de rees/minutes/seconds or decimal degrees:
g g g ud iV46i ."I s ,, iili.
(if well field,one laatt/•lloo�ng is sufficient) 22.Certification:
3y,g 5-g, 0.� N 1/►/p f I D t b L ( W s e
d044,LJ
6.Is(are)the well(s) Permanent or EITemporary Signature of Ce red Well Contra or Date
77''`` 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: rlYes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information nd explain the nature of the copy of this record has been provided to the well owner.
repair under 421 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: �1 SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: "t A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdperent(example-3@200'andd/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 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: M ad r U--Ck r Y construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,iUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
f
13a.Yield(gpm) Method of test: D 11 M 10 41 O 24c. For Water Supply&Iniection Wells: In addition to sending the form to
T the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: I It Amount: 1 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016