GW1-2021-00787_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: "�
J Y 14.WATER ZONES
Well Contractor Nam FROM TO DESCRIPTION
ft. r��
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a livable)
�f ' „ t l� n\�t D yI�'t FROM TO DIAMETER THICKNESS MATERIAL
+f y ��� u `� 1 ft. ft. ' in. v�
Company Name
C, 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: L C)bU 102 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: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. D(_P ft. in. d�a O
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft. fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. oZ 1 ft. ni Drh
❑Monitoring El Recovery
Injection Well:
❑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 r ft. ft. ii- !1
❑Experimental Technology ❑Subsidence Control fr'�o'f
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Rc-
TO DESCRIPTION(color,hardness,soiltrock type, in size,etc.)
Q ft. ft. d
4.Date Well(s)Completed: 1� Well ID# ft. ft. a
5(a�Well Location: ft. ft. n - n 1'
ft. ft.
Facility/Owner Name Facility IDD#�(if applicable) /� f pipt. ft. Y� 41
�1 1 N6lA Ml n l �' U�\V t I L ��j�p j v
Physical Address,City,and Zipft.
(/�' �, 1\ Y'e-� J 1 VISA JJ
21.REMARKS
County yParcel Identification No.(PIN)
I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 1�(�j r� 22.Certification:
_ iSi� N v Ib I r ttl qa W `
��/ i`Z2!�4
q -�
6.Is(are)the well(s): rmanent or ❑Temporary Signa ure of Certi d Well Contracto Date
/��� _J By signing this form,I hereby cern/v that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: El or 0 1 SA 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 at d 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: 11 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: lQ (ft.) Submit this GW-1 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 to Division of Water Resources (DWR),
10.Static water level below top of casing: C) (ftJ Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
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 27699-1611
13a.Yield(gpm) Method of test: IJYh r"Pi
13b.Disinfection type: Amount: I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018