GW1-2021-01170_Well Construction - GW1_20211215

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
FROM TO DESCRIPTION
,Wl Well Contractor Name p� ft. ft.
.c e\) c- 94lJ A ft. fit.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
�`1 bby well
d2i 1 V vQ sxC. FROM ft TO r ft. DIAMETER in THICKNESS MATERIAL
o Company Name t r i �YL
16.INNER CASING OR TUBING eothermaI closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERW
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft.
Water Supply Well: 17.SCREEN
PP Y FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. I In.
hldustrial/Commercial Residential Water Supply(shared) 18.GROUT
1rri ation FROM TO MATE L EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft- t ft. G o n &
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
( Aquifer Recharge nGroundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM I I MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. fit.
Experimental Technology DSubsidence Control fit. fit.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiUrack e, rain size,etc.)
Geothermal(Heating/Cooling Return) ! Other(explain under#21 Remarks) fit t fit.
RocX-
4.Date Well(s)Completed: 1 Well ID# L4
fit. t ft.
t
5a.Well Location: ft, (D lJ1 ft,
ft. ft.
Facility/Owner Name ��q/� Faciliitty`ID#(if applicable) ti• ft.
yRcr OAS, I lf-tQ15V1 t 1 IYCt r-O2®9 ft. fit.
ft.
Physical Address,City,and Zip ft.
21.REMARKS
02
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: ( (�
6.Is(are)the well(s) Permanent or �Temporaty
dBy
ure of Certified Well Contractor Date
�TT gning this form,I hereby cent that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes orNo 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)Ideexplain 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
a
9.Total well depth below land surface: ' n -(fit•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100) construction to the following:
t
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:LQ (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
,A _ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:A-c 1 1 R 1 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 276994636
13a.Yield(gpm) 016 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 typel&?01 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