GW1-2021-00360_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well C�(o'ntractor Information:
l t`� lY 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
tol ft. � ft• ��{( Sari
1
NC Well Contractor Certification Number 15.OUTER CASING for multi-caied wells OR LINER if a, licable
FROM TO DIAMETER TffiCKNESS MATERIAL
,O_1ft. in. O
Company Name SC6r
t n'4p q 16.INNER CASING OR TUBING' cothermal closed-too
2.Well Construction Permit#: V V t/ v � 1 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. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_ Agricultural [3Municipal/Public '��ft. ' I ft. fin• 'Oka
D Vt-
_I Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
_ Industrial/Commercial Residential Water Supply(shared)
18.GROUT
_ I17i ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. r
Monitoring ORecoveiy ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery �ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
__.Aquifer TestIStonnwater Drainage aft, l fLa (`
_ Experimental Technology r.IISubsidence Control ft. ft.
BGeothermal
Geothermal(Closed Loop) r1ITracer 20.DRILLING LOG(attach additional sheetsif neeessi�)(Heating/Coolinrg�Retum) FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc)IOther(explain under#21 Remarks) � ft. � It.
A_6 1
4.Date Well(s)Completed: I 3 Well ID# ft• a ft' C
5a.Well Location: ft. ft.
ft. Oft.
Fafcility/Owner Name Facility
ID4(if applicable ft
le) ft. �I ft. `, S
1 a 0 NQu� nt l.0 1 De Rb/1b'B's7 O — ft 1 . �tLl
Physical Address,City,an tp t —7 T. It. S
21.REMARKS
County Parcel Identification No.(PIN) `v qrid no'I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1 Orl— O
(if well field,one lat/long is sufficient) 22.Certification
6.Is(are)the well(s) ermanent or EITemporary Signature of Ce ed Well Contfetor "' Date
T77" By signing this form,1 hereby certify ithat the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EIYes or JTNo 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 n 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-i 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: I� A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di(j'erent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 3fl (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: V (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
1 above, also submit one copy of this form within 30 days of completion of well
12.Well construction method:(Y\ud construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY
YYIWELLS ONLY: 1636 Mail Service;Center,Raleigh,NC 27699-1636
13a.Yield(gpm) O Method of test: 1rA 24c. For Water Supply&Iniecktion Wells: In addition to sending the form to
U 't the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1 '� Amount: `1 completion of well construction pto 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