GW1-2021-00705_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. (-P+ft
a y� 0,rt
ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR LINER(if a livable)
FROM TO DIAMETER THICKNESS MATERIAL
`\ 1 1 ft. 1 9 ft. I A in. SLf I%A a O V�
Company Name r
✓� �g yam, 16.INNER CASING OR TUBING.(geothermal closed-loop)
2.Well Construction Permit#: 1 ��J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Counh',State,Variance,etc.)
3.Well Use(check well use): ft. ft. in•
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 13 ft. `4�ft. CIP, in.
1 r
❑Geothermal(Heating/Cooling Supply) )Wesidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri anon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C) ft. vet. "V*_-r*U-N1 Z Jc D b
❑Monitoring ❑Recovery
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 C20 ft. Cp ft. say-id, r
❑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,soiUrock type, rain size,etc.)
© ft. ram ft. t) s O it
4.Date Well(s)Completed5-U Well ID# ft' A
5a.Well Location: 1 ft. 2 2 ft. 6y e a
KP\\S I OaarrnS ft. 3 ft. eA n G/rn
Facility/Owner
ame Facility ID#(if applicable) �(ft. (0 ft.
4 � N� n
M i tS ft. �v ft.
Ph sical Address,City,and Zip �?� 4 p ft. fL ,
/l�IMb�iJrNAI � 110ar 21.REMARKS
County 1 Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) ^� n 22.Certification: /
3`4 1 / 5 ag (;31 N t -1 "��"1�� W
liGi9�1i"I i
a w
-1
6.Is(are)the well(s): LbPermanent or ❑Temporary Signature of Ce ed Well Contracto Date
////"`` By signing this form,I herekv cernify that the well(s)was(were)constructed in accordance with
7.Is this a repair t0 an existing well: ❑Yes Or 00 15A NCAC 02C.0100 or 15A NCACO2C.0200 Well Construction Standards and that a cop),
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: 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"+"
p W 24b.For Injection Wells: Copy to DR,Underground Injection Control (IUC)
11.Borehole diameter: `nrn (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:`'i ` kA zoy��r 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) U 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: U 1
t,13b.Disinfection type: H Amount: 1/4 C' LO
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018