GW1-2021-00363_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
' n
1�r 14,WATER ZONES
Well Contractor Nanle FROM TO DESCRIPTION
3 ft.
ft. ✓ ft 1 J
NC Well Contractor Certification Number 15.OUTER CASING for iuulti-cased wells OR LINER(if a' livable
FROM TO DIAMETER TMCKNESS MATERIAL
ft'
Company Name _ -AoY
VC-
I� ��` 16.INNER'CASING OR TUBING.`"eothermal closed-loop)
2.Well Construction Permit#: A 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.
SCREEN
Water Supply Well: 17.
FROM TO DIAMETER I SLOT SIZE I THICKNESS MATERIAL
Agricultural [DMunicipaUPublic 2 ft, 3�ft, a in. 1a S ,I i�V p arc-
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) J ft. ft. in I e�1 '1
_. Industrial/Commercial Residential Water Supply(shared) 18.GROUT
7_11rrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: _ �-
Monitoring13Recoveiy
Injection Well:
ft. ft.
_;Aquifer Recharge Groundwater Remediation 19:SAND/GRAVEL PACK 1f a licablc
Aquifer Storage and RecoveryISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
__;Aquifer TestIStonnwaterDrainage a0ft. 3 ft. Ai
Experimental Technology r.11Subsidence Control
l7lGeothermial(Closed Loop) r.1ITracer 20.DRILLING LOG(attach additional sheets if`necessar '
_i Geothermal(Heating/Cooling Rerain size,etc.)
^^turn) (Other(explain under#21 Remarks) rt. ft. � ft.
FROM TO DESCRIPTION(color,hardness,soil/rock type,
4.Date Well(s)Completed: d 0 Well ID# J ft. ,a ft.
Sa.Well Location:
ft.
�t n 1 ft. ?J ft.
So L4
F cility/Ow erName FaciliryID#(ifapplicable)
_Aun�r�lit'
Phys'cagAddre;ss!6Ci;ty,;andZip f[. ft' 2
1� b13 0113 21.REMARKS
County Parcel Identification No.(PIN) ''
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35° 19 an N `lib 3�,�81 W La ao
6.Is(are)the well(s) Permanent or [(Temporary Signature of C tified Well Con 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: DYes or 00 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 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 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: 35 A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2 tr 100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: U (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
(� a above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: MVa
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) 1 Method of test: DU VAP k 4\ 24c.For Water Supply&Iniection Wells: In addition to sending the form to
'r the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 11 completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016