GW1-2021-00702_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
-Sy 14.WATER ZONES
Well Contractor Name
2 FROM TO DESCRIPTION
�t. 3-1 ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a livable)
y` FROM TO DIAMETER THICKNESS MATERIAL
-"1 ft. ` 3 ft. a in. '3Lh
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
`�
2.Well Construction Permit#: V 'CA< d V�'^��V FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,Count),,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 3 3ft. ft. in. v--(_
❑Geothermal(Heating/Cooling Supply) 1.4sidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. '1 ft. i�et,1.��/ ►� 1^
❑Monitoring ❑Recovery ft. of ft. ►/
Injection Well:
❑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 (Dft. 3q IL
❑Experimental Technology ❑Subsidence Control
❑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,soittrock type,grain size,etc.)
n ` D ft. a ft. S E
4.Date Well(s)Completed: v 1 Well ID# ft. , ft. 4,1 n l N
5a.Well Location: / ft- / ft. A Vt (A
JfJli(]�5 0nn1 R- �0. q ft. 2 ft. n ct h
Facility/Owner Name Facility ID#(if applicable) aft. 2 ft.
-+ G.
Ph sical Address,City,and Zip ft. ft.
Xxm\_ ,�1��\ 21.REMARKS
County V t✓ \ 0� Parcel Identification No.(PIN) DEC 08 mi
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification: „-
2uy .qL(qoue_f N 1$ ,g35249 W
p r
Cl-3�.a�
6.Is(are)the well(s): W.ermanent or ❑Temporary Signature ofCertidbd Well Contract# 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 100 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
lfthis is a repair,fill out known well construction information an 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 i GW-i is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 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')
24a. For All Wells: Original form to Division of Water Resources (DWR),
If Static water level below top of casing: (ft.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use"+"
11.Borehole diameter: (in,) 24b.For Injection Wells: Copy to DWR, Underground Injection Control(iUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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
r� Permit Program, 1611 MSC,Raleigh,NC 27699-161 1
13a.Yield(gpm) 1 Method of test: / t
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018