GW1-2021-02301_Well Construction - GW1_20210722

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Informatio/n:
:14:WATERZ0NES;
Well Contractor Name FROM TO DESCRIPTION I
� us IL i fL
lya ft /�S ft
NC Well Contractor Certification Number ///��� A '45.OUTER CASING for,multi-cased wel tOR:LINER if a"'licgble. .` !<'
J I /JOOLe we 11 -Pulw FROM TO' DIAMETER ' ,THICKNESS MATERIAL /
( 1/V r(/(J Cl „I/ iL-. — in. V Ci�G/ GCS
Company Name '
16.114NER CASMG 01t,, ING, eothermal closed=loa
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i e.UIC,County,State,Variance,etc.) ft. fL
3.Well Use(check well use): ft ft in
- .
Water Supply Well: l.SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultura
Geothermal
QMunicipaVPublic 0 fL ft.
(Heating/Cooling Supply) Residential Water Supply(single) ft• ft• In.
Industrial/Commercial DResidential Water Supply(shared) 1&GROUT
_ I711 Ration FROM TO MATERIAL 1 EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. C ft
Monitoring J Recovery ft. ft
Injection Well: I
Aquifer Recharge QGroundwater Remediation ft. ft
19 SAND/GRAVEI:'PACR if a licable.; -
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage rL ft
Experimental Technology E)Subsidence Control ft. ft
I
Tracer 20:DRILLING LOG'.attach additional s8 Geothermal(Closed Loop) � eetsifn"`
Geothermal(Heating/Cooling Return) EI Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soiVrock rain size,etc.)
fL ft 5
4.Date Well(s)Completed: - Z Well ID# ft ft. C eL
5a.Well Location: ft ft /Q^t�L
le r3 ft
,
Facility,/owner Name Facility ID#(if applicable) ft ft' I
SUv 1 K l/l T rein L4jt/( /# Z ft. ft I :�
Physical Address,City,and Zip ft fL nun ��11Z
:21'REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IatAong is sufficient) 22.Certification
�5 38 U,4gb1 -?g 3& ql. Z-7 0 W
6.Is(are)the weil(s) anent or Temporary ature of cerhfi ell Co Date
By signinprin,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or [RNo with 15A 7VCAC 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 remorks 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 OD'an�d'12Q100') construction t0 the following:
10.Static water level below top of casing: V (ft.) Division of Water Resources',Information Processing Unit,
I f water level is above casing,use-4' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
24b.For Injection Wells: In addition Ito,sending the form to the address in 24a
i above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: r construction to the following: l
(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
/ 1
13a.Yield(gpm) "'1 Method of test: �/-j 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 type: f'/ 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