GW1-2021-00544_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information-
y 66 toe 14.WATER ZONES
Well Contractor Name
FROM TO DESCRIPTION
`b I ft ft.
b;
ft. '6 ft. A`
NC Well Contractor Certification Number I5:OUTER CASING for,muitl-cased wells OR LINER if a lieable
Gh Y Q eh&
�,`e fl ¢ �uMp
FROM TO DIAMETER THICKNESS MATERIAL
W 6 rt. 414 ft. in.
Company Name J
I (� 16.INNER CASING OR TUBING eothermal closedaoo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permirs(i.e. UIC,County,State,Yariake,etc.) & ft, in.
3.Well Use(check well use): & ft. in,
Water§upply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public {t, ft, in.
Geothermal(Heating/Cooling Supply) RRcsidcntiaI Water Supply(single) tt. ft. in.
Industriakommercial DResidential Water Supply(shared) I&GROUT
Trri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
ft. ft. 1 4'�{
Monitoring DRecovery
Injection Well:
Aquifer Recharge OGroundwater Remediation
19.-SAND/GRAVEL PACK(if a lieable
Aquifer Storage and Recovery Salinity Barrier FRONT I TO I MATERIAL, EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft,
Geothermal(Closed Loop) Tracer 20.IDRILLINGLOG attach additional sheets ifnetess
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION col r hardness WI/rack a ins' Me
ft. ft. + s bill
4.Date Well(s)Completed: Well EN ft. 0 ft. d K
5a.Well Location: {t' 00 ft, G 4t a LA M i tG l
exift. ft.
t9 h rb
Facili i0wner Name Facility 1D#(if applicable) ft. ft.
47L O7 a &V K e15 t t' r ft. ft.
Physical Address,City,and�Zip ft. ft.b
REMARKS
County Parcel Identification No.(PIN) 10rt ' r r r a
i P4�,3 r.A"il
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latrlong is sufficient) 22.Certi cation:
N W
6.Is(are)the well(s)dPermanent or OTemporary- Si tore f Gertificd well Contractor Date
By signing this form,1 hereby cerlifir that the xrll(s)ivas(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or eNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Canvirucrimi Standards and that a
1f this&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#11 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.
dolled: 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: U1DA) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple{cells list all depths if dif/erenn(example-3g:00'and 20100) COnSLIUCtiOn to the following:
10.Static water level below top of casing: [7 (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: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: I
above, also submit one copy of this form within 30 days of completion of well
�( r r p 6tr
(ie.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
J 13a.Yield(gpm) E.0, Method of test: !J D t+" 24c.For Water Supply&Injection Wells: In addition to sending the form to
i the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 2 9 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016