GW1-2021-00766_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Con
tractor Information:
� tl '� �3 14.WATER ZONES
Well Contractor Naing FROM TO DESCRIPTION
A� -3 A a 1 ft. a 5 S(cm
ft. ft.
NC Well Contractor Certification Number
1 15.OUTER CASING(for multi-cased wells)OR LINER(if aDDlicablel
yq e k 1 D f) FROM I TO I DIAMETER THICKNESS MATERIAL
1 ft 01 ft. a in. SLhyl7 vc—
Company Name 16.INNER CASING OR TUBING eother al closed-too
2.Well Construction Permit#: FROM TO DL4METER THICKNESS MArERIAI
List all applicable well construction permits(i.e. UJC,County,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 �Municipal/Public ft 5 ft in.
Geothermal(Heating/Cooling Supply) [IResidential Water Supply(single) ft.
�hy� PvC
,
ft ft. in.
InduStrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation nFROMTO
O MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: aOft.Monitoring MRecovery ft.Injection Well:
ft._ Aquifer Recharge Groundwater RemediationAquifer Storage and Recovery Salini Barrier VEL PACK(if a licable1y MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft aS ft- *a e _�a1
_1
Experimental Technology �ISubsidence Control ft. fa ��c
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 soil/rocka rain s;ze etc.)
ft � ft -
4.Date Well(s)Completed:01 a g-a� Well W# ft. ft
5a.Well Location: 1n ,� ft. ft.
Facirlity//O�wnerrName 1FacilityID#(ifapplicabllee)f�l� ft. ft.
�/ o' !-� a� w mu Il�, we aJ"� I ft. ft
Physical Address,City,and Zip ft. ft
����SDIr✓ +��'n1_]��'1 l I 21.REMARKS t
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/iong is sufficient)
I� 22.Certification:
3+) �f 3 t�� N �q W
6.Is(are)the wells) Permanent or ❑ITemporary Signature of C ed Well Contra or a ;p4! --zi'
By signing this form,1 hereby certifv that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or o with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information a d explain the nature ofthe copy ofthis 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-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: 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'aand 2@I D0� construction to the following:
]
10.Static water level below top of casing: / (ft-) Division of Water Resources,Information Processing Unit,
Ifwarer level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: LP (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
.Well construction method: R�1�M „� above, also submit one copy of this form within 30 days of completion of well
(l�l t
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test: tom P(M 24c. For Water Supply&Iniection Wells: In addition to sending the form to
H-TH ` the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: L( 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