GW1-2021-00804_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well
Contractor Information:
Well ntractor �o � 14.WATER ZONES
FROM TO DESCRIPTION
ft. 3 ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER(if a licable
I �`' i I t FROM TO DIAMETER THICKNESS MATERIAL
l (/L V ( ft. 33 ft. in. I SCb 1, 1(
Company Name 1
` "2-
16.INNER CASING OR TUBING cothermal closed-loo{�2.Well Construction Permit#: 1 I 1 I 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.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:)Agricultural E)Municipal/Public 33 ft. 3^l ft. in. © PN t;�
:]Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in. `
Industrial/Commercial (Residential Water Supply(shared)
18.GROUT.' ,
1tri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. tt. 19
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
_ Aquifer Recharge ElGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [3ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer TestIStonnwater Drainage a ft. ft.
Experimental Technology ISubsidence Control
__, Geothermal(Closed Loop) r.1ITracer 20.DRILLING LOG(attach additional sheeti if ncccssar)`
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc)
__i Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) Oft. Y ft.
ft, ft.
4.Date Well(s)Completed: o� a Well ID#
5a.Well
�Location: �(� � n ft. rl` ft.
Am
)D `l l.�w _ ft. 3d� ft. 1_
Facility/Owner Name Facility ID#(if applicable)
J`v� t AS �� J ft. ✓ fL E�•�-r'-�/, t i
Physical
Address,
\ A dtdd rI ess,City,and Zip
pSVo C5jl 21.REMARKS
RK
� ft.
t
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'
N ' '1g IaO���� W ace a
6.Is(are)the well(s)II}t 7ermanent or [(Temporary Signature of Ce fied Well Contiftor Date
T 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 p_1ANo 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 plain the nature of the 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
v
9.Total well depth below land surface: 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00') constriction to the following:
10.Static water level below top of casing:Ho (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: (in.) 24b.For Injection 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: Mika vb�QV14 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) V Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also subrnif one copy of this form within 30 days of
13b.Disinfection type: Amount: Vi 947- completion of well construction to the county health department of the county
where constructed.
4
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016