GW1-2021-00355_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Lc ry Tf 14,WATER ZONES
Well Contractor Nam
FROM TO DESCRIPTION Li
ft. f
ft. 1 Q(1 n
NC Well Contractor Certification Number 15.OUTER:CASING"for'n ulli se w Its OR LINER,if a 'lica e
FROM TO DIAMETER THICKNESS {MATERIAL
ft. ft. ,°� in.
Company Name v`
16.INNER CASING OR TU[i1NG''eottiermal closed=loo '
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. VIC,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 SIZETHICKNESS MATERIAL
_.'Agricultural E)MunicipaUPublic ft. `,i ft. in-
-V 1 G
:)Geothermal(Heating/Cooling Supply) residential Water Supply(single) 51 ft. ft. rl in. �/ 5,
Industrial/Commercial Residential Water Supply(shared) 18.GROUT. o�
hYi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
DMonitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge [)Groundwater Remediation
79.SAND/GRAVEL-PACK if a' ltcahlc
Aquifer Storage and Recovery E]ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:.)Aquifer Aquifer Test O Stonnwater Drainage `a 0 ft. 55 Sam r
Experimental Technology [7ISubsidence Control
BGeothermal(Closed Loop) OITracer 20.DRILLING'LOG(attach ridditional sheets`if n&&sa '
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,ete)
C)ft. q ". tp 5o 1 \
4.Date Well(s)Completed: Well ID# ce3k, ft. ft.
5a.Well Location:'
k r\5 k
ft*
ft.
a C-
Facility/Owner Name Facility ID#(if applicable)y� ft. ft.
ft
5
p W g
3t� tJ f
Physical Address,Cit , d ip 5 1 ft. ft.
21.REMARKS
County V Parcel Identification No.(PIN) '`f '•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: l
(ifwell field,one lat/long is sufficient) 22.Certification:
\°\,gi N t 513 Wza��
6.Is(are)the wells) Permanent or OTemporary Signature of Cel red Well Contr tor; 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: n yIes 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 informationP,,dexplain the nature ofthe copy ofthis 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:- 5-5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiereni(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 1 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"/�+" 1617 Mail Service Center,Raleigh,NC 27699-1617
l
11.Borehole diameter: `T (in.) 24b.For Infection 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:eVA(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) t V Method of test: V l 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: I Amount: / Ci completion of well construction to the county health department of the county
where constructed.
Foim GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016