GW1-2021-00709_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES,
Well
FROM TO DESCRIPTION
tra t Nae
ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING for'multi=cased wells OR LINER(if a' livable
\i; , \ ►�1 FROM TO DIAMETER THICKNESS MATERIAL
\ \ y +A 2_1 ft. I a in. D
Company Name
16.INNER CASING OR TUBING 'eothermal closed-loop),
2.Well Construction Permit#: - LDS 3 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. it. in.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 3'1 ft. q ' ft. 9. in. ,N(_
t�
:),'Geothermal(Heating/Cooling Supply) R'Residential
esidential Water Supply(single) ft. ft. in.
Industrial/Commercial Water Supply(shared) 18iGROUT:, .,
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring [)Recovery
Injection Well:
ft. ft.
_ Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL-PACK if a `licoble
Aquifer Storage and Recovery ),'
ecoveryISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_;Aquifer Test (®I Stonnwater Drainage t d ft. ft. r
Experimental Technology E]ISubsidence Control
Geothermal(Closed Loop) r.1ITracer `20 DRILLING LOG(attach idditiiial sheets if it&issa' '
BGeothermal(Heating/Cooling Return) 3IOther(explain under#21 Remarks) FROM DESCRIPTION,
(color,hardness,soiUrock type,grain size,etc.)
0 QL✓� ft. TO ft.
4.Date Well(s)Completed: 1—�-0_10 Well ID# ft. ft.
rt. ft.
Sa.Well Location: p y�
�VI n�l I 1 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. 3�l ft. r Cw
�Q z Woo 0 0A-s G t&' �R er Mi% ft. ft. f
Phy'�aI Address,City,and Zip Q ft. ft. 0-EC 0 8
Al�mbeX� �t(3a _3u3 17 21.REMARI(S
County Parcel Identification No.(PIN) 77
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well Veld,one lat/long is sufficient) 22.Certification:
3-1 5gt31 N 180 ,53-dW W w -7-
6.Is(are)the well(s) ermanent or []]Temporary Signature of rtified Well ntractor 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: nYes or No 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 ojthe 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
q.
9.Total well depth below land surface: I 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@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: (in.) 24b.For Iniection 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) 1� Method of test: m 1 24c.For Water Supply&Iniection Wells: In addition to sending the form to
1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type. J Amount: 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