GW1-2021-02302_Well Construction - GW1_20210722

' I'rint':�orm
WELL CONSTRUCTION RECORD(GW7.1) 7em_al Use Only:
L Well Contractor Information: -
:._ `'14 i:WATER ZONESs -:•. .;. , ,.... ,
+ cll Contractor Name FROM TO 1�5 DESCRIPTION
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C Well Contractor Certification Number z As.OUTER CASING:fdi'_inidti4hased wells_ORi&INER if a'""llcable
Po o Ie, (fie f k PVl'b FROM TO DIA TER THICKNESS MATERIAL
. (Company Name tt `7 ft- in; . i0
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16.4NNER CASIN6,011 ]Na ebtherinal closed=loo
.Vi'ell Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
F.ul all applicable ivell construction permits(i.e.UIC,County,Slate,Variance,etc.) fL fL in.
J.Well Use(check'well use): ft. fL in.
-;1y:SCRE>N
f`Ti ater Supply Well: -.:.• :-. ...„, ..,:
! FROM TO DIAMETER SLOI SIZE THICKNESS MATERIAL
t�Agricultural OMunicipal/Public 0 ft. ft.
[jGeothennal(Heating/Cooling Supply) residential Water Supply(single) n, g, in.
s�Industrial/Commercial Residential Water Supply(shared) 18:GROUT
IIITIga[IOn FROM T MATERIAL EMPLAC ENT METHOD&AMOUNT
Non-Water Supply Well: nft.
I Monitoring _)Recovery fL ft.
Injection Well:
ft. fL
DAquifer Recharge OGroundwater Retnediation
19..SAND/GRAVEL`PACK ifa livable
t_1lAquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test OStormwater Drainage ft. fa
Experimental Technology Ej Subsidence Control ft. fL i
QGeothermal(Closed Loop) Tracer ;20;DRILLING.LOG'.attacliadditi5iialthoets ifnecesss
j Geothenmal(Heating/Cooling Retum) Other(ex lain under 921 Remarks FROM To DESCRIPTION(color,herdocs soiUrock rein sin,etc.
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'.Date Well(s)Completed: D 2 Well ID# n- G ft.
.Well Location: GS fL Q fL C4_,%,1 a�
Facility/Owner Name Facility ID#(if a plicable) fL ft. v) 9
U C �� P 6t �tl ,��- ft. fL �1 _ , 1
Veit
Pliysical Address,City,and Zip Q� ft fL n5
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Init I I� ,2I RE14ARKS.
County Parcel Identification No.(PIN)
ab.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if n ell field,one lathy is sufficient) fi
] _ 22.Certica'
10
_=.ls(are)the weli(s)oPermanent or Temporary ofCerti ctor Date
Dy signing this form,i hereby certify that the'ivell(s)ivas(ivere)constructed in accordance
7.is this a repair to an existing well: QYes or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
f this is a repair,fill out knoivn well construction information and explain the nature ojthe copy of this record has been provided to the well oiwter.
r impair under 1/21 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: SUBMITTAL INSTRUCTIONS
?.Total well depth below land surface: OS (tL) 24a. For All Wells: Submit this form within 30 days of completion of well
Fnr naehiple wells his[all depths ijdifferent(example-3@200'and 2@100') construction to the following: j
'P.Static water level below top of casing: 00 (ft.) Division of Water Resources!Information Processing Unit,
lfwatei level is above casing,rcre"i-" 1617 Mail Service Center,Raleigh;NC 27699.1617
+.1.Borehole diameter: (in.) 24b.For Injection Wells: in addition fo sending the form to the address in 24a
t above,also submit one copy of this form within 30 days of completion of well
2.Well construction method:
—T-- construction to the following:
i.e.auger,rotary,cable,direct push etc.)
i Division of Water Resources,Underground Injection Control Program,
!'FOR WATER SUPPLVELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13n.Yield(gpm) Method of test: ��W 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: Amount: ,�h completion of well construction to the"county health department of the county
-' where constructed.
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For in GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016
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