GW1-2021-00713_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor fI�nfor^m'ation:-�e�J� y
!mil i 'v i V V 1 11 U 1 U l J 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
NC Well Contractor Certification Number 1S.OUTER CASING for multi-cas'ediwells ORLINER if a lie 1Te
V t I��[ �n(6 (�;ril,>f�,() FROM TO DIAMETER THICKNESS MATERIAL
J V ` ` ` Ji ' t \7�( Pq ft. in. �,+O
Company Name
�,_® ^`��/ n 16.INNER CASING OR TUIIING'' eothcrmal closed-ES
2.Well Construction Permit#: olf din 1..1" 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. ft. in.
Water Supply Well: FROMREE TO DIAMETER ' SLOT SIZE THICKNESS MATERIAL
:;)Agricultural Municipal/Public a( t. f3'2 t. �1°• , (,hy d PJ -�
:,,)Geothermal(Heating/Cooling Supply) rResidential
esidential Water Supply(single) ft. ft. in.
_I Industrial/Commercial Water Supply(shared) 18.GROUT::
hYi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. QC) ft. I1�1 Lk S. pc)uIF
:)Monitoring Recovery `��
Injection Well:
ft, ft. I
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a' 7icahlc "
_I Aquifer Storage and Recovery EISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IStonnwaterDrainage IX �ft. 3�ft- a sand
_I Experimental Technology r.1ISubsidence Control
_;Geothermal(Closed Loop) �ITracer 20.DRILLING LOG(attach additio»ai sheets if necessar
_I y
Geothermal(Heating/Cooling Return) i IOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc.)C>
1
4.Date Well(s)Completed: 07- Well ID# ft. ft.
5a.6nv�mn
ell Location: ft. ft.
skv xt 1 ft- ft.
Facility/Owner ame V Facility ID#(if applicable) 'a ft. 33 ft.
F� -1 \J`�V`V�C ft. ft
Phy '1c�al,Apd�dr�ess,City,and ip ft. ft.
� 21.REMARKS
LULI
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/lonng is sufficient)
Q 22.Certification:
35 N e J'1� N 1 U qJ ��� W t
6.Is(are)the well(s)Oermanent or OTemporary Signature ofigertified Well C ftractor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ojthis record has been provided[o the well owner.
repair under 421 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdderew(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,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: `` (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
1 �Q A 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) 0 Method of test: 24c.For Water Supply &Iniection 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: 1M completion of well construction to the county health department of the county
where constructed.
Foim GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016