GW1-2021-00797_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
t
1�1A N 1`1 i�j� 1Y 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
IL
O San
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a livable)
�\\ L� ` ; FROM TO DIAMETER THICKNESS MATERIAL
} 1 ft. I D 9 rt. c- Sur,y i7 V C
Company Name
16.INNER CASING OR TUBING'(geothermal closed-loop)
2.Well Construction Permit#: W 1 O` ,oI J� FROM I TO I DIAMETER THICKNESS I 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 in. t 0 P v c
❑Geothermal(Heating/Cooling Supply) 1Aesidential Water Supply(single) ft. oC O ft. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C2 ft. QQ :L501 h
❑Monitoring ❑Recovery ft. ft. ��
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
❑Experimental Technology ❑Subsidence Control
❑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,soittrock type, in size,etc.)
ft. C1 ft. 1 V S D 1 1
4.Date Well(s)Completed: _ r oZ 1 Well ID# a ft. ft.
5a.`Well
�Location: ft.
V Co\< tr�io�rd 1 g fL a ft. �a. C
Facility/Owner Name Facility ID#(ifapplicable) daft.
13i"3 Val a r d iZc�l NCw'ror� C-ro_N-e Nc: a ft. ft.
Physical Address,City,and Zip
�lI`61(��TJ� I I �.� .�y D / 21.REMARKS
County Parcel Identification No.(PIN) USt p
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification:
id� `I \O5 N _ t � SD JJ Welj
t
6.Is(are)the well(s): Oermanent or ❑Temporary Signature of Ce ified Well Contrac r 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: Dyes or �0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a coPy
1f this is a repair,fill out known well construction injormation 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 I GW-I 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(s (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(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: / (ft.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+".
LO_ 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter: (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Yyw �Ao Yl,,, 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
13a.Yield(gpm) �� Method of test:
1Y� Permit Program, 1611 MSC,Raleigh,NC 27699-161 1
13b.Disinfection type: - I Amount: A
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-20I8