HomeMy WebLinkAboutGW1-2021-02543_Well Construction - GW1_20210805 .Prini Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Nainc FROM I TO DESCRIPTION
6 ft. 1374, f"
31c, ft. i Ito ft. J401 10.il
NC Well Contrictui-C'enification Number IS.OUTER CASING(for multi-cased wd!q�LRIifap 'iiaWRIA1
Ttt.,.,�
FROM TO I DIAMETER I \�, 1 111.1
fif,)p C ft. in.
Company Name T
16.INNER CASING OR TU RE G fipl!,er nl closed-loop)
-9 FROM r D_.. . THICK\ESS MATERIAL
2.Well Construction Permit#: 1 TO A Tj R
far. ("nom. I"11-fall,c.rh'I I to.2 I;_
to ft• ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply NN ell: FROM TO DIANIETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3m ft. I* in.
Geothermal Hic:,tina,Coolina Suppiv) r.i,
. 19 esidential Water Supply(single)
lndustrial/Ccn--..-i,:.%it~! nResidential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring Recovery ft. ft.
0
Injection Well: ft. i ft. 1z i
Aquifer Rechu: nGroundwater Remediation 19.SAN WG RAVEL PACK{if applica Iet
Aquifer StoraL, and 1tecover.v rlSalinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
AqUiller Test nstorm\%raler Drainage fr. ft.
Experimental Subsidence Control ft.
I
Geothermal 1,00pl [3Tracer 20.DRIL ING LOG(attach additional sheets if necessary)
FROM ! TO Geothermal tll-_--_i-:!�g,Cooling Return) MOther(explain under 921 Remarks) DESCRIPTION(color.haittim,soillrock typt.grain size.ete.)
0 ft.
4.Date Well(s)(ompleted: I-IL ZJ Well ID# ft.
17(b5_7 ",
ft. ft.
5a.Well Locatin,):
F
S r axA C4% Hy I C-6 gy ft. ft.
I
Faciliq'0%\ner Nuw:� Facility ID4 tif applicable) ft.
o Pe or- L e-L 94 (*-arAete Nc 18'71S--
Physical Address.01\.;tnd/ip ft. IL f
21.REMARKS 777
Count\ Parcel Identification No.WIN
5b.Latitude anti iongitude in degrees/minutes/seconds or decimal degrees:
tpv
(if well field,one la lor,_i,sufficient) 22.Certification:
35,,3q, 1q. b 3 73 Hl"- 2. a' aS. q 4
6.Is(are)the%vi,;I(s)04/r-nanent or [3Temporary It Date
8V nu),form,I hereh.1 th,ul ffie wvffisJ wu.%tiverei c(insiructed in accardance
7.is this a repa;-tonn existing well; E]Yes or ��No wilh 15A;%CAC 0-Y"WhIl ar l;A.%'C.4(,02t Irmo Well Cominicium Standards and that a
11,111 Hit"rintawn wnlexrdaw the mintre 4the
repairunder M,hock,y lIns,form. 23.Site diagram or additional well details:
8.For Geoprolac!DPT or Closed-Loop Geothermal Wells having the same You ma` use the back of this page to provide additional\vell site details or well
construction.or)i• I ('tt-I is needed. indicate TOTAL.NUMBER of\vells construciton details. You may alsouttach additional pages if necessary.
driile& SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this' form within 30 days of completion of well
Formulliple well.. "w.a,-pilt,it,h(l.ivoi l,,xwnplv. construction to the following:
10.Static water.ic!below top ofeasing: Division of Water Resotirces,Information Processing Unit,
IfI,wler/eve/I.,an, Imo 1617 Mail See-vice Cen4er,Raleigh,NC 27699-1617
11.Borehole diarrieter: (in.)
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above. also submit one copy oftfiis torn wizhin 30 days of completion of well
12.Well constr!.-, rot-thod: go Via!2!:�) construcizon.to the follov.,ing:
(i.e.auger.rotas.c:,ole.j,ttct push-cic
Division of ater Resources,!
W iU dcrground Injection Control Program,
FOR WATERct PHA WELLS ONLY: 1636 Mail Service&I'Iter,Raleigh,NC 27699-1636
13a.Yield(gpm) a 5 Method of test: ac& CC4A2)9%(K 24c. For Water Sunniv& Iniection Wells: In addition to sending the form to
the addresses) above. also SLIWit i oric copy of this form Within 30 days of
.13b.Disinfectiwi!Ve- C%toi,Jy,_e Amount: 74!!ktL,v completion of well construction to the count v? health department of the county
here construted.
is
Fonn Gt%-I North Carolina Department of Environmental Oualny-;,)I%tsion ofAValer Rc;ojr is Revised 2-22-2016
Recourses
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