GW1-2021-00798_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: j
1.We 1 Contractor Information: w
1 • 14.WATER ZONES
Well Cop�ractor Name FROM To DESCRIPTION
0'C/1 9 ft. ft. Y�' S GIMP
ft. ft.
NC Nontractor Certification Number
I f 15.OUTER CASING for multi-cased wells OR LINER(if a licable
f FROM TO DIAMETER THICKNESS MATERIAL
13 tL �'1 O� in. VI
Company Name � 1
W O ' 16.INNER CASING OR TUBING m eolheral closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County, tale• 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 foMunicipal/Public 3-1 t. -Aft. a in.
l P la,
Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
Industrial/Commercial !(Residential Water Supply(shared)
18.GROUT
_ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: © ft. tt. yv
12
:)Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge13 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable),
_I Aquifer Storage and Recovery rIISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IStormwater Drainage
ft. ft.
Experimental Technology QlSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessai `
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
[]Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) -oft. ft. O Sol'
4.Date Well(s)Completed: 1 Well ID# ` ft. ft. A C f Q
I
Sa.Well Location: Yft. G 7
ft. A
C�(1�1MAD CIO, r� ^ fc. 2 � ft. and ela
Facili /Owner Name Facility lD#(ifapplicable) o� ft. 3// ft. Ee til0.
3 L ;
7 ft. a ft. r�` 4'�^ � yr-
Physical Address, ity,and Zip ft. 1 ft.
21.REMARKS
County Parcel Identification No.(PIN) -�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t:'
rfwell field,one Iat/lon is sufficient 11�llP UN I
( g ) e 22.Certification:
N v� ir15`7 R�`0 W G t ,J c t I�� 2-16.Is(are)the well(s) ermanent or OTemporary Signature of Certi Well Contractor, Date
By signing this form,1 hereby certify,that the well(s)was(were)constructed in accordance
7.Is this a repair to an enlisting well: 1IYes or o with 15A 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 a Explain the nature ofthe copy 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 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: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100� construction to the following:
I
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
11.Borehole diameter: Le (In•) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: i
(i.e.auger,rotary,cable,direct push,etc.)
i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) O Method of test' 24c.For Water Supply&Iniec tion Wells: In addition to sending the form to
—( I the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: I 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