GW1-2021-00791_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
La r�l >L 11%"�tad .1 r .
14,'WATER ZONES.
Well Contractor Name FROM TO DESCRIPTION
ft, fL Yl S Gf A
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER if a licablc
FROM TO DIAMETER TffiCKNESS MATERIAL
0 ft. in. I .S�i PVC
Company Name
',,! 16.INNER CASING OR TUBING "eotheritral closed-loop)
2.Well Construction Permit#: Vr G 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.
Water Supply Well: 17i SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public 0 ft. '311ft. S,-H L1 d PYG
_;Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial EResidential Water Supply(shared) 18.GROUT,
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: © ft. O ft. ee ditl l e uar 3-sal u 5
Monitoring ORecovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation _
19:SAND/GRAVEL PACK ILa`licablc - '
_'Aquifer Storage and Recovery [3ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
__'Aquifer Test OStormwater Drainage 0 ft. a ft. sc.rL t)UY
Experimental Technology []]Subsidence Control
Geothermal(Closed Loop) lTracer 20.DRILLING LOG(attacli additional sheets if ncces"sa' '
__)Geothermal(Heating/Cooling Return) Ell Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,softock type,grain size,etc)
d ft / ft I S
4.Date Well(s)Completed: �� 'y Well ID# ft. ` ft. e- 1 6kw? Q S' n ' Goa
5a.Well Location:
'�q ya7lna R e e -/ f[. U ft. YRnCie
Facility/Owner Name Facility
� G OID#(if applicable) Oft. 2 ft. �� A
1 /0 Ine II)Lx r 1\ P— N Dun n C p 3g f(� ft. J ft.
Physical Address,City,and ZipLi �I �/ (� ft. ft.
S A r1Dso n/
I V 6' a I�3y l 21.REMARKS E� a s. A,1' I
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3�° 1 D•3 l'� N 3� y 9 2- w �.✓ ' >-� —a?-Z o Z°
6.Is(are)the well(s) ermanent or EITemporary Signature of Q&Aifled Well Con ctor Date
OF 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: Yes or with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this retard 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 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: 1� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 ! (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdperent(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,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
V1�t j e above, also submit one copy of;this form within 30 days of completion of well
12.Well construction method: I r 1 rU Tc Y Y 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
I
13a.Yield(gpm) 15 Method of test: till JK 1 nC 24c.For Water Supply&Infection 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: 1 1 Amount: 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