GW1-2021-00497_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information::
l"0 �/ ' C,�s 14 WATER'ZONES
Well Contractor Name FROM TO DESCRIPTION , •;-,^tq ''0 S, t Gill!
ft. R
NC Well Contractor Certification Number 15.OUTER CASING for maltitased wells UR1 INER if a flnble
rr oY, -k— w e. 1 \ �- 0 FROMTo DIAMETER TfficIINFSS MATERIAL'....
Company Name r ft Q 3 ft in
2.Well Construction Permit#: re,-d'G lJV' I J g FROM R CtTO oRnTUB��RINGIge6ther I THICKNESS
NESS MATERIAL l
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: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. Crt. 1, in. / G /< VC
❑Geothermal(Heating/Cooling Supply) GResidential Water Supply(single) ft. fL
❑Industrial/Commeroial ❑Residential Water Supply(shared)
yF18;GROUT
❑lrri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT MEtHOD&AMOUNT
Non-Water Supply Well: © fL d ft. 1 ( p tAre
❑Monitoring ❑Recovery ft. ft
Injection Well:
it. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEI PACK(ifitpolicablel
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage R- R•
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach-additional sheets tf necessary).
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,sail/mck size,eta
D ft. 3 ft. G�r
4.Date Well(s)Completed:. 3- 21 Well ID# ft. Q % G 1
5a.Well Location: CAL lir— R
a .Sao 4 r,l� .mod & a- ft- tl
Facility/Owner Name
r� Facility lD#(if applicable) ft. ft.
�r a / ' 1^� C ft. ft.
Physical Address,City,and Zip iL n.
J r1 S N 21.'REMARKS .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: ? Q
N WL'�-
6.
Is(are)the well(s): A rernument or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ;No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out!mown well construction information and explain the nature of the 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 page to provide additional well construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: No 1,/ (R) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 a 00'an 2Q100)
D 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"(+"
11.Borehole diameter: l7 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AO loy 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county Were installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: ,
13b.Disinfection type: 1J Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resouices Revised 6-6-2018