GW1-2021-01990_Well Construction - GW1_20210620

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
J1 Y_ 4, t /�'tC/�A, 14.WATER ZONES
Well Contra for Name FROM TO DESCRIPTION
J��J � ft. 95 ft•
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wtils OR LINER if a lieabk
_���� ©t/�/�^�^1_ �C FROM TO DIAMETER THICKNESS MATERIAI.
j� fl. ft. in.
Company Name
�/J p 16.INNER CASING OR TUBING(geothermal closed-Ira
2.Well Construction Permit#: Z�" dS 'kA<H —U�7�� FROM TO I DIAMETER I THICKNESS MATERIAL
Livi all applicable hell construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in
3.Well Use(check well use): tt, ft. in
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mun cipal/Public rt. R, in.
❑Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) tt tY. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GROUT
❑Im ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
ft.
❑Aquifer Recharge ❑Groundwater Remediation ft.
19.SAND/GRAVEL PACK f a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets If necessary)
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) FROM To DESCWPTION(cobr,Asrdsess solUrock e, trio sin,etc.)
ft. ft.
4.Date Well(s)Completed 7—ZJ Well ID#
5a.Well Location: ft. ft.
nlez d�� rt. rt. _
Facility/Owner Name Facility iD#(ifapplicable) ft. ft.
ssiAg
1711 4r .i A, �/ /�.,../��� Z7?/S rL ft. — Informs lon on
Physical Address,City,and Zip --T- ft. ft. LA
a,14111 21.REMARKS
County Parcel identification No.(PIN) _ZZlleyl ez.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce 'flea• n:
03.379 N 32. 7Z3 Wt��
6.is(are)the well(s): 8Pf—rmanent or ❑Temporary Signature ofCertifie Well Contractor Date
By signing this form.t hereby certify that the wells)ryas(were)constructed in accordance xith
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC OX.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature ofthe ojthis record has been provided to the well oµ+ter.
repair under#21 remarks section or on die 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 construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �t�6" (ft.)
For multiple wells list all depths ifdii erent(example-39200'and 2(0,1001 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: aC S (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If enter level is above casing.use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11,Borehole diameter: (in,) 24b. For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
I Well construction method: ✓ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i..ee.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gym) ?(I Method of test: 0/ d Permit Program, 1611 MSC,Raleigh,NC 27699-161 l
,Jp
13b.Disinfection type: 67 z Amount: 7 /O?.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018