GW1-2021-00362_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Law el,l &a 1- 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
lllJt� � 3afL 3Sft. q n �!'i
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a livable)
FROM TO DIAMETER THICKNESS MATERIAL
1 ft. 3t:;t ft. °a in. Sc�j'L�1 vC
Company Name
t�✓ _ _ t 16.INNER CASING OR TUBING( eotbermal closed-loop)
2.Well CODStrUCtlOn Permit#:-\al!� �11 �► FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,CounrY,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 3aft. t. in'
-Dl a -LQ
❑Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial 2Residential Water Supply(shared) 18.GROUT
❑bri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. Oft. i�ehh I/
❑Monitoring ❑Recovery ft. ft. pair
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage It. -3 5ft. *a
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
�I D ft. ft. O se,1' 1
4.Date Well(s)Completed: -1 3" Z Well ID# I clOt
5a.Well Location: `�.p a eakn a-W h I�e C A CL
Y li p ft. a fL - a I a
Facility/Owner Name Facility ID#(if applicable) 3 9.
3 ft. ft. J
:V
Physical Add.., 't ,and Zip ` (� �j ft. ft. ^ � -
1�)1 1 1 a D 3-1 21.REMARKS
3 o "
County f Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwelelfifield,one]at/long is sufficient) ([ ryn 22.Certification
3J o��l a`1 atI N O t �05"1��D W
w
6.Is(are)the well(s): p 'ermanent or ❑Temporary Signature ofCe red Well Contr for Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or *0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a coPy
If this is a repair,fill out known well construction information and explain the nature of the 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: ec 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ) (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
(ft.) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
If Static water level below top of casing: Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: U4� 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) 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
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: I rv,0 1
1
13b.Disinfection type: ^1T Amount: A
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018