GW1-2021-00721_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information-
L
14.WATER ZONES
Well Contractor N��ame FROM TO DESCRIPTION
ft. � ft. v
ft. ft. I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a livable)
�/11�i FROM TO DIAMETER THICKNESS MATERIAL
C \ ` +-, fL �1 ft. in. LkL ��
Company Name
� `` _ 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: \).P S dLQ Ow 1 I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Count.yt 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 ❑Mu icipal/Public � 1 ft. ft. in.
❑Geothermal(Heating/Cooling Supply) B�Kesidential Water Supply(single) ft. et. 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. R.
i
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑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 Oft. ft.
❑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,grain size,etc.)
Q ft. ft. ,
4.Date Well(s)Completed: D )>b Well ID# ft. ft. R
5a.Well Location: ft. ft. �P Q
Facility/Owner Name Facility ID#(if applicable) ft. ft. a n
��la �uNl�t ft. ft.
Physical Address,City,and Zip ft. ft.
`/„ = 21.REMARKS 0
County Parcel Identification No.(PIN) 1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) p COS-9
22.Certification:
N 78 t W r l
` �i ear
6.Is(are)the well(s):*ermanent or ❑Temporary Signature of C hied Well Con tor. Date
/ By signing this form,I hereby certifi,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
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: 3` (ft.) Submit this GW-I 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 W to Division of Water Resources (DR),
If Static water level below top of casing: (ft.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
f water level is above casing,use"+11"
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
Permit Program, 1611 MSC,Raleigh,NC 27699-I61 1
13a.Yield(gpm) Method of test: /
13b.Disinfection type: L4 Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Rescind es Revised 6-6-2018