GW1-2021-00801_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information �� Y
14,WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
NC Well Contract ertification Number
,C � 1 n 15.OUTER CASING for mulli-cased wells OR LINER if a licable
V 1
�p.1 f -0\/`I ,\( , F 1 M ft. T ft. D ETER in. THICKNESS
RI MATERIAL
Company Name
{�(�'� �\ 16.INNER CASING OR TUBING keolhermal closed-loop)
W W 2.Well Construction Permit#: L- �O - � t/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. VIC,County,State, Variance,e1c.) 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 DMunicipal/Public vl ( ft. I ft. ?n• O k� P G
:)Geothermal(Heating/Cooling Supply) tResidential
esidential Water Supply(single) 1 ft. ft. in• v
Industrial/Commercial Water Supply(shared) -
18.GROUT.,
llri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. a ft. jZ,en��.jl a
Monitoring Recovery f[. ft. ✓
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicablc
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:)Aquifer Test E]IStonnwater Drainage Po ft. it q ft. # u-Y+
Experimental TechnologyISubsidence Control ft. l ft.
B
Geothermal(Closed Loop) ITracer 20.DRILLING LOG(attach addiflbnal sheets if necessary)'
Geothermal(Heating/Cooling Return) IOther(explain under#21 Remarks) I
FROM TO DESCRIPTION(color,hardness,soillrock type min size,etc.)
ft. � ft.
4.Date Well(s)Completed: Well ID# ft. ft.
Sa.Well Location: ft. ft. +an
�a�15 a M-Z- f[. ft. o
Facility/Owner Name r Facility ID4(if applicable) f[. ft.
N . � � '
L1✓lY`\/�1L 1� 1J1�n � l"� °1 ft. I`7-ft.` :v
Ph sical Address,City,and Zip ft. ft
SI(N(�� � 0 a 21.REMARKS
County 1 1 ) Parcel Identification No.(PIN) lJV
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification: '\
N "1 ` WX04444 I,
6.Is(are)the well(s) Permanent or OTemporary Signature ofCe red Well Contr for Date O�
"`777��� By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes 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 a formation d explain the nature of 1he 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-I 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 ifdi[Jerent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resotrces,Information Processing Unit,
Ifwater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
M above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: \\\ w6m 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) to Method of test: 10 24c.For Water Supply&Iniection 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: Amount: i/'�1 completion of well construction to the county health department of the county
where constructed.
t6
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources E Revised 2-22-2016
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