GW1-2021-02251_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14,WATER ZONES,,,,
FROM �- TO DV�FRII
Well Contractor Name fL Sam
fL W _
U(_"� Cka- —
NC Well Contractor Certification Number
,,15.-OUTER,CASING(for ulti6cased 11s)OEILIMR 1i able)
I To wells
FTM 'ir!9
(\c FROM ft. I DtAME�ER EVS MATERIAL
lr� ft. (01 �in.
Company Name
16.1MVER-CASING-01t: ING(jetithermil 696aitnJI)l
2.Well Construction Permit#: to 0 t 0 6r C\ 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: 47.SCREEN' .FROM TO DIAMETER SLOT
SUE THICKNESS- MATERIAL,
j Agricultural 13Municipal/Pubtic ft. ft. in;.
Geothermal(Heating/Cooling Supply) E)Residential Water Supply(single) in.
Industrial/Commercial 5<sidential Water Supply(shared)
18.GROUT.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it. oZO ttt1cretc
3Monitoring DRecovery
Injection Well:
r-&Aquifer Recharge oGroundwater Remediation
�-19.,SAND/GRAVEL PACK:(if:apoliiabli),,,
Aquifer Storage and Recovery 13 Salinity Barrier FROM TO MATERIAL I EMPLACEMENT I I METHOD
Aquifer Test OStormwater Drainage
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG(attach additiohaUsheets;if n&eisiry)
Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sail(mck typc min size,etc.)
ft.
4.Date Well(s)Completed: OZ Well lD# /S
5a7JVeI1 Location:
YJ C E?T11 CC IEkq _�c
Facility/Owner Name Facility ID#(if applicable)
RQ_n kX-S n'l l l le t Physical Address,Address,City,and Zip
1VRE MARKS,�,,.',
AUL
Gk 55 S-1 S 4A 56
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattiong is sufficient) 22.Certification:
6 0\ N W nu
6.Is(are)the wcll(s)crPermaneut or 13Temporary Signature of Certified Well—ontractor Date
e'e'ee 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: [)Yes or [RNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
i
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 pag el to provide additional well site details or well
1
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may alsOattach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: it-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001
construction to the following:
1 0 C:)
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: (Q (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 ONLY: nn 1636 Mail Service eenter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: N� 24c.For Water Suyvlv Sk Injection Wells: In addition to sending the form to
the address(es) above, also submitI 'one copy of this form within 30 days of
13b.Disinfection type: Amount: t., C) 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