GW1-2021-00419_Well Construction - GW1_20211206

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
��/� S $6�r ` ��►\ 14.'WAT ZONES
l FROM z TO D CRIPTION
Well Contractor Name
1) J f
(A4 ft L 5 c� t.
NM"Oe'"
nhactorCertification Number 400o . 4.g ft
15.OUTER CASING for muitii-casedGwells OR:L R if a licatile 1,
�( 1 1\l K FROM TO DIAMETER THICIQHESSMATERIAL\ 1 p ft. I q ft C' ( 4 in.
Company Name ^ 16,INNER CASING.OR TQBING
of eothermai':closed=loo"
2.Well Construction Permit#: ,0 �— d U 3-1-1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. it. in.
3.Well Use(check well use): fL it. in.
Water Supply Well: 17 SCREEN .
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
Agricultural OMunici blic ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. fir, ft.
Monitoring Recovery tt. fL
In
Well: Qa
ff. ft.
Aquifer Recharge Groundwater Remediation .rr Y
19.SAND/GRAVEL-PACK'if a"'ticable ,
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage
ft. ft.
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additioniil sheets if necessa
Geothermal satin Coolie Return Other(explain under#21 Remarks aftt-
TO DESCRIPTION color,herdn soiltrock ` in s" etc
� t• i)t�i� �
4.Date Weil(s)Completed: a a Well ID#
5a.Well Location: ZS 0 ft.
P, f o S"ar a 25 oft. c�.g aft
Facili /�P Ow�re amN e� �^ FacilityID# tf ticable ¢ ft. � ft. /�
3 VI ��te A Sh r GlY�M Tr,,:\ Off c % G DK T
Phys' 1 Address,City,and Zip
ft. ft.
2r REMARKS.
:1 nP1A ON F'ROCES.%ru U14
County Parcel Identification No.(PIN)
I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N _�a° �4 ' 369 .� W �
6.Is(are)the well(s) ermanent or 13Temporary Signature of Certified Well Contractor Da
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: ®Yes or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy ofthis 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 ells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (0 (IL) 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@1/00) construction to the following:
10.Static water level below top of casing: (0-0 00 Division of Water Resources,Information Processing Unit,
if water level is above casing.use"+"G 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection 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: ©� 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) 3 Method of test: ��` 24c.For Water Supply&Injection 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: 20 O Z completion of well construction to 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