GW1-2021-01075_Well Construction - GW1_20210322

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Informal in:�Cl S 00 0 14.WATER ZONES
Well Contractor Name FROM I TO DESCRIPTION
�aft. ❑.A ft. n.
NC Well Connector CertificationNumbs, 15.OUTER CASING for mold-cued wells OR LINER cable
(j y- y 1(Ile I l e G Well � 1 �A�P ��c EOM TO DIAMETER THICKNESS MATERIAL
a.
Company Name V
✓
�� ^��7 16.INNER CASINGOR TUBING eoWermsl closed4
2.Well Construction Permit#: d 1 FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable cell construction permits(ie. U1C,County'State, Variance.etc) ft. R. in.
3.Well Use(check well use): ft. ft. rn.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOTSIZE I THICKNESS I MATERIAL
Agricultural IT
icipaUPublic R. fL fa
Geolhcrnal(Heating/Cooling Supply) 1DResidential Water Supply(single) n. ri la
IndustriaVCommercial [)Residential Water Supply(shared) la.GROUT
bri ation FROM TO MATERLIAL EMPLACEMENT METHOD&MIOLTlT
Non-Water Supply Well: 0 tt. 10 tt' rt -1VA dt a rQ V r fy
Monitoring Recovery ft. ft.
Injection Well:
Aquifa Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK Ha Iinhle
Aquifer Storage and Recovery [)Salinity Barrier FROM TO MATERIAL EMPLACEAIF.NT METHOD
Aquifer Test QStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG istuch additional sheets IftRcessa
Geothermal eatin CODtin Return) Other(ex lain under#21 Remarks) not" TO DESCRIPTION cob,h mhotia,caiFrock in ae.
G ft. 2 fL 'I
p'� �� ���]�� I
4.Date Wells)Completed:1_L=` Well ID# Z n. Cj ft City
Sa.Well Location- n. ft. I rJC-
Aacj t1 MaIJ00101A ft. ft.
Facility/Owner Name
� Facility lD#(ifapplicahle) ft. ft.
/ .
3 L)L &A r V\ ��� I I ft. ft.
Physical��A.}ddd City,and Zip // ff. n.
4�b�f�rarnklln 28a1 - 7 �- 6W�a 21.REMARKS v
Caunry Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification: ,{D
N W
6.Is(are)the weli(s),dPer imment or [)Temporary Sigoa f Cmificd Well Cil macmr Date
By signing this(can,I hereb) cernift that the well(s) was(were)romYructed in accordaue
7.Is this a repair to an existing well: [)Yes or VpNo with 15.4 NCAC 01C.0100 or 15A NCAC 02C 0200 Well Couvuc#an 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 remarks section or on the back of dirt 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: j SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3// G' IffJ 24s. For All Wells: Submit this forth within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2rVw) construction to the following:
1
10.Static water level below top of casing: (J (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above caring,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:_ (in.) 24b. For Inleclon Wells: In addition to sending the form to the address in 24a
l above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: �U 10.r'� construction to the following:
(i.e,auger,rotary,cable,direct push,ac.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: �/- , ,k 1636 Mail Service Center,Raleigh,NC 2 7 699-1 63 6
13a.Yield(gpm) .' .h- Method of tesC 61 QtN 24c. For Water Sootily & Injection Wells: In addition to sending the form to
' �� the address(es) above, also submit one copy of this forth within 30 days of
13b.Disinfection type: NTH Amount• completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Eavironmenral Quality-Division of Water Resources Revised 2-22-2016