GW1-2021-00800_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
L`y" \ I`\( ly 14,WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
�<7 VG� `��ft. ^� ft. st V n
ft. OC ft. Vn
NC Well Contralor Certification Number {� 15.OUTER CASING for multi cased'wells OR LINER(if a Gcable
FROM TO DIAMETER THICKNESS MATERIAL
J_ ft. 4 ft. in.
Company Name "i
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: "� l/ 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. ft. in.
jai .�11Q hyc� Pv�
:,,)Geothermal(Heating/Cooling Supply) esidential Water Supply(single) in.
Industrial/Commercial _;,1 esidential Water Supply(shared) 18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring DRecoveny
Injection Well:
ft. ft.
_ Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a'li&blc
Aquifer Storage and RecoveryI Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStonnwater Drainage oft. A �r
Experimental Technology �ISubsidence Control ft. O( ft.
BGeothermal(Closed Loop) OITracer 20.DRILLING LOG(attach additional sheets if n&essar
Geothermal(Heating/Cooling Return) []I Other(explain under#21 Remarks) I FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,eta)
ft. cSOI I
4.Date Well(s)Completed: 11 aD"0) ell ID# ft. ft. VoA- &-_�, 1
5a.Well Location: oY ft. ft. rA W �l V��
uka � `J l�l 1 C/ as ft. a` ft. Q 0-& n li[11
Facility/Owner Name
/��'�p ftl� Facility IDD#(if applicable) ft. J ft r
Physical Address,City,and Zip i(� I�� 18 ��( ft. ft. DEC 0 8
sarnose� Iq I1D to 1q[0 a p 1 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
";5, ?g N `�� I qu3°�4 W
6.Is(are)the well(s) Permanent or 1ITemporary Signature of ified Well Contra or Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EIYes or No 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 n explain the nature of the copy of this 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
i
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 if dieretu(example-3@@200'and 2@100') construction to the following:
10.Static water level below top of casing: D (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: (Y (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
1 110 �w�� above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1 1 � 1(J1 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
13a.Yield(gpm) 0 Method of test: I 24c.For Water Supply&Injection 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: Amount: 1 completion of well construction Ito the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016