GW1-2021-00339_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.We 1 Contractor Information:
' t/
u/ 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
n ft. ft. ay•S e so
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if ap livable)
FROM TO DIAMETER THICKNESS MATERIAL
J__J 11. 1 .9 F ft. in. ISCj0,14C) PV'
Company Name r v
16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: 3 5;� S FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,Counh',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 MATERIAL
❑Agricultural ❑Municipal/Public �ft. ft. in. 1
❑Geothermal(Heating/Cooling Supply) tsidential
stdential Water Supply(single) ft. ft. in. 1�
❑Industrial/Commercial Water Supply(shared) 18.GROUT
❑1ni ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q 0 (b h
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
[]Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage Qoft. )a� ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRELLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
O ft. ft. '501
4.Date Well(s)Completed: Well ID# n. c/ ft. A n V1 clav
5a.Well Location: �.�y" �.^ t� ft. a�+ ft. n 1ex
V D5 r 1U,G �T\ l ItXJ fL � ft. Q n
Facility/Owner Name Facility ID#(if applicable) ft. 3
`, `- I ' ,?San
t zn-,cr �Y 1 V�.% 1LD� l�Jl�
G
9D 3 F'
Physical Address,City,and Zip ft. ft.
s�
Rb'es DY, t' c>05'0�01,;t 04 21.REMARKS
r iwf._ii,c.
County Parcel Identification No.(PIN) ••- �^'"`
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
i,.Ic;
(if well field,one Ia`Ul�ong is sufficient) l ,, 22.Certification:
N �OIIP �� W ,
6.Is(are)the well(s):Aermanent or ❑Temporary Signature of CI red Well Contra or Date
By signing this form,I hereby certii i'that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and Hurt a copy
If this is a repair,fill out known well construction information a d explain the nature of die 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-39200'and 2(?P100')
10.Static water level below top of casing: (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
1f water level is above casing,use"+"
11.Borehole diameter' (in,) 24b.For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
�� Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: . IZ_ G Vx'x 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) o county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: 1 hi Amount: l
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018