GW1-2021-00878_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD (GW-1)
For Internal Use Only:
1. Well Contractor Information: T(E jet E..m
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Well Contractor Name lVt t p AUt\ 1 lJ 2021
res51ng Unit
NC Well Contractor Certification Number Ii:farR �tton RCC .
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NaFr6 t�� 1' l C D\NR Section
Company me �i
2. Well Construction Permit #: 3) fJ ' / 1
List all applicable well constriction permits (i.e. UIC, Cminty. State. Variance, etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Hcating/Cooling Supply)
❑lndustrial/Commercial
❑irrigation
❑Muni ipal/Public
Biiesidential Watcr Supply (single)
❑Residential Water Supply (shared)
❑Wells > 100,000 GPD
Non -Water Supply Well:
❑Monitoring
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Wells) Completed: Y' /
5a. Well Location:
Facility/Owner Name
J.06 SQrre( Oft_
❑Groundwater Remcdiation
❑Salinity Barrier
❑Stomtwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
Well iD#
PritPoo;� 4
Physical Address, City, and Zip
FrG r
County
Facility ID# (if applicable)
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
6. Is(are) the well(s): I 1 rmanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or QNo
If this is a repair, fill out known well construction information and explain the nave of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 0 LI (ft.)
For multiple wells list all depths if different (example- 3Q200' and 2Q100)
10. Static water level below top of casing:
If water level is above casing, use +"
11. Borehole diameter:
V
(11•)
(ft.)
12. Well construction method: t' C o 1' e C
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY: j ./
-
13a. Yield (gpm) 7 Method of test: tr/lL'.0
13b. Disinfection type: 14 ri 1�( Amount:
Ifb
Form GW-I
14. WATER ZONES
FROM
TO
DESCRIPTION
f6
l SCo ft.
7 6-P
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if a
livable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
/ R.
,S ft.
6 in.
/8k-
(,GiL,
16.1NNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
R.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft
in.
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT/
METHOD & AMOUNT
O fL
a 0 ft.
/7ole�l t(%9_
G'W rP0
ft.
ft.
UU
t/
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
R.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (goiter. hardness. soWnsek type, grain size, etc.)
Oft.
3 ft.Toj2$
'(
3H•
a)ft.
c/4t
c7G f
So R-
_Sane
cU ft.
-), r R.
CNyr,n . T -r
R.
ft.
ft.
ft.
H.
ft.
21. REMARKS
S'lee/ lycre/er }'tn,i'e 5h,,e
22. Certification:
Signature of Certified Well Cohtractor
3�-a/
Date
By signing this form, I hereby certify that the well(s)was (were)constructed red in accordance with
ISA NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a copy
of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
(add 'See Over in Remarks Box). You may also attach additional pages if necessary.
24. SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection Wells: Copy to DWR, Underground injection Control (TUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells producing over 100,000 GPD: Copy to DWR, CCPCUA
Permit Program, 1611 MSC, Raleigh, NC 27699-1611
North Carolina Department of Environmental Quality - Division of Water Resources
Revised 6-6-2018