GW1-2021-00342_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Informiation:
hl� f N 1\� 7 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
�ft- `
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for'multi-cased wells OR LINER if a `livable
FROM TO DIAMETER THICKNESS MATERIAL
Company Name V- ft. qD ft. a in: I SL.IgD PVL
16.INNER CASING OR TUBING'(geothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc) +ftt
ft. in.
3.Well Use(check well use): ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:,)Agricultural [DMunicipaUPublic ft. ft- !n• D`Cb J_SRLk0 N(,
:,')Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. fL in.
Industrial/Commercial �IResidential Water Supply(shared) 18.CROUT
IITi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. D ft. i
Monitoring _I Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK If a licable
_I. Aglllfer Storage and RCCOVeryISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStonnwater Drainage D ft. S ft. s1 r
Experimental Technology FnI Subsidence Control
__ Geothermal(Closed Loop) ITracer 20.DRILLING LOG(attach additional sheet';if necessa
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiltrock a rain size,etc.)
-
4.Date Well(s)Completed: 1�-� ocQ Well ID# ft. ft.
5a.Well Location: ft. ft.
KeNAO izavGp as ft. ".
Facility/Owner Name
,� /� �Facility I\D�#y(ifapplicable) 3�ft. -1 ft.
o�\IAICi �� 9�l.�J�y I�tl� �� Gllt. %� ft. m
Ph%s'calAddress,City,and Zip ft. ft
besuy, a a�<-0�4-c�Si) 21.REMARKSCounty Gt� Parcel Identificatioon No.(PPTN)V
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3A i-ILPO lk3 N 19 , 9g0U0 l W P io -7 a0
6.Is(are)the well(s) mane ernt or OITemporary Signature of CfAified Well Co ctor; Date
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: EIYes or with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided the well owner.
io I
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 if ditierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 122 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+"r ^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: lX (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: JMA kO-M 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) Method of test: I 24c.For Water Supply&Iniection 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: Amount: l 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