GW1-2021-02218_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
�Q�r11 CS eo-V 1\a'`(v-� 14.WATER ZONES
Well Contractor Name FROM TO D CRIPTION
ft M
R'o.qls— '` ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a--licable
R �'„'w e.M `I ` ` %� FROM TO DIAMETER_ THICKNESS MATERIAL
o iN y Name Cn \\ oft ft
Company Name
16.INNER CASING OR TUBING `eothermal c1osed46601
2.Well Construction Permit#• a a 0 0 a a 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 nDIARSLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft.Geothermal(Heating/Cooling Supply) _- si ential Water Supply(single) ft. it.
IndustriaL/Commercial Residential Water Supply(shared)
1&GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. a 0 & �O-Awo �.-f S � 1
Monitoring Recovery ft. & �'�C� 1 F>
Injection Well: M�& A4
ft. ft.
Aquifer Recharge Groundwater Remediation
19iSAND/GRAVEL PACK.if,a licable
Aquifer Storage and Recovery 13 Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology E3 Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 120ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,suitlrock type,gmin size,etc
u. (93 ft. v e r bur
4.Date Well(s)Completed: Well ID# (o 3 ft. N 4-S ft-
Well Location: 14--S ft- VS,, R'
C7 -S O ft. ' Os ft.
5 .
1 A-o r Qo o (�
Facility/Owner Name Facility ED#(ifapplicable) ft. ft.
`��c�Q, Q
ft. ft. ,
IDS �e.�rer C�� � C , Ca��� �-,� 1
Ph ical Address,City,and Zip r ft. ft. t 11
an 3 0 g 7 1 I 2L REMARKS 6
Ss�n9
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
$J1�3 t 5B0�0
(if well field,one lat/long is sufficient) 22.Certification'
`31 N 1)c;A W O/z,,� f 4 I a
6.Is(are)the well(s) __ ermanent or Temporary Signature of Certified Well Contractor Da
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or 2 �o 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 and explain 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 I GW-1 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 if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (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: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS O Y: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test- L% 24c.For Water Supply&Iniection 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: TA Amount: C5 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