GW1-2021-00728_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
�y- Y V\ \yNt�1`) FROM TO DESCRIPTION
14.WATER ZONES
Well Contractor Nname
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a licable
FROM TO DIAMETER THICKNESS MAT,E`RIAL
V V\ + i ft. I L-Q' ft. in.
Company Name 1
16.INNER CASING OR TUBING eotherntal closed-too
2.Well Construction Permit#: FROM TO DLAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e. UIG County,State, Variance,etc.) ft ft. in.
3.Well Use(check well use): ft. tt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MMA,T/ERIAL
Agricultural �Municipal/Public ft. ft. in. uLe S Lko 1 V
Geothermal(Heating/Cooling Supply) 2esidential Water Supply(single) ft. ft in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHO &AMOUNT
Non-Water Supply Well: ft. t7D ft. ,� 1 Z 1_ Imu r
Monitoring Recovery tt. lJ ft. 17
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if a licable
_ Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test D Stonnwater Drainage 120
ft. I 1 I ft �.r
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) r.7ITracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rocktype, rain size,eta)
ft ft A0051D` \
4.Date Well(s)Completed: --;>CVell ID# ft. ft. 5�hAu CAQW
1
ft. 1a ft.
1
Sa.Well Location: 1 Or
iytd)reorV,\ aaft N ft.
Aan
Facility/Ow
n
�`'(er Nam Facility
Van j� nK Facility ID#(if
capplicabllee/)) 1 (l.},O` ft. f „t ft.
�+ \ L Cam\ s��� l/r 1`� lv ly�`I lY \ ft. �lY ft .n-
Physical Address,City,and Zip ft. ft. '
"6 n KS 21.REMAR
County ice• Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwelll(field,one lat/long is sufficient) 22.Certification:
N 1 1 t OfJ \� W
6.Is(are)the well(s) ermanent or Temporary Signature of V
ified well Cor#actor Date lJ
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes or No with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information 6IRexplain the nature of the copy of this record has been provided to 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 1 GW-1 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: q I (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdperent(example-3 ,20e0'and 2@1001 construction to the following:
10.Static water level below top of casing: J (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: U (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Imo," above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: M\36 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) Method of test: m 24c. For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also sub m typit one copy of this form within 30 days of
13b.Disinfection e: f l Amount: CLI completion of well construction to the county health department of the county
M.-constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016