GW1-2021-00334_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
1'� `11� y�j3 14.WATER ZONES i
Well Contractor Nate VVV FROM ft TO DESCRIPTION
. c) ft. San 01
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased;wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
` — ft. ID ft. in. ® P f
Company Name
16.INNER CASING OR TUBING cotbcrmal closed-loop)
2.Well Construction Permit#: �I ") 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.
Water Supply Well: 17.SCREEN..
FROM i�T7�
SLOT SIZE THICKNESS MATERIAL
:)Agricultural DMunicipal/Public l nbft. • ac` P\f�__I Geothermal(Heating/Cooling Supply) esidential Water Supply(single) w ft. •
_; Industrial/CommercialIResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
ft. a(pLft.- vQ\ b r t _ _ 5p 1b
Monitoring Recovery ft. ft. t�r� DU r
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicablc
_j Aquifer Storage and Recovery [)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
-_.Aquifer Test L�IStonnwater Drainage a 1 ft. 1a a ft. 4a a
Experimental Technology 0ISubsidence Control ft. ft
Geothermal(Closed Loop) (Tracer 20 DRILLING LOG(attach additional sheets if necessary)
_ FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
I Geothermal(Heating/Cooling Return) �)Other(explain under#21 Remarks) ft. ft. tD 5DI,
4.Date Well(s)Completed: ��(� Well ID# ft. 1 ft. so'Ac CI
5a.Well Location: ft. l Cj ft. +an CA
1 R L/lt LU Ne �V 1 T ft. 00 It.
o
ft. ft. vlsand'--,--'
Facility/Owner,Nlame 1 (� Facility ID#(if applicable) � -
1� VV 1111�5 M i� �VYy! 'N� ft. ft. r p r !
Physical Address,City,and Zip ft. ft. Ut 202
tv(�m 21.REMARKS
l � �i FkJ.;�`��
County Parcel Identification No.(PIN) 11 iv,
)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) ® ^ 22.Certification: q
3so 1 1 ,p q N 1 D �5, I� W & \ 1-10 pA
6.Is(are)the well(s)OPermanent or UITemporary Signature ofCewd Well Contra r 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: nIYes 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 and explain the nature ofthe copy ofthis record has been provided 16 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: Sco (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierew(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: `I3 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 10 (in.) 24b.For Injection 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: V Y construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I Method of test: 24c.For Water Supply&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: �f t Amount: �'Z W, 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
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