GW1-2021-06940_Well Construction - GW1_20210505

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
�lUl�156^ 6171 ias'8 n la.WATER ZONES .x
FROM TO I DESCRIPTION
Well Contractor Name
ft. ft.
y 3- A rt. ft.
NC Well Contractor Certification Number 15.OlJTER CASING'1or.multi cased wells OR LINER(if a livable
�Q�V`��A ' FROM TO DIAMETER THICKNESS MATERIAL
I h,C • ft. R. in.
Company Name
1 I� 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#• to 10C.�b b 1. FROM I TO I DIAMETER ITHICKNESS I MATERIAL
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.) 305 ft. D ft. t,YJ�X2 in. C `` �) x 3
w
3.Well`Use(check well use): ft. ft. in. J 1 Wt-as
17.SCREEN
[Geothermal
Supply WeII: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAcultural Municipal/Public ft. ft. in•
hermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in•
strial/Commercial ®I Residential Water Supply(shared) 18.GROUTation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Water Supply Well: 3D ft ff. et M ("t, m e xy�(1itoring Recovery ft. faS
ion WeII: ft. ft.
ifer Recharge Groundwater Remediation19.SAND/GRAVF.LPACK 'fat livable ifer Storage and Recovery rISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ifer Test nStormwaterDrainageerimental Technology Subsidence Control ft. ft.
hermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessat )
FROM TO DESCRIPTION{color,hardness,soil/rock e, ram size,etc.al(Heating/Cooling Return) ;Other(explain under#21 Remarks) n. fr. Y
4.Date Well(s)Completed: Well ID#
rr. rc.
5a.Well Location:
Facility/Owner Name ,, �Facili�ty�IDI!(if applicable) rt. ft.p
rt. ft.
Physical Address,City, d Zip rt. ft. ��Pit
'Rum 0MLe- *ZL433149900000 21.REMARKS �r �
O�
County Parcel Identification No.(PIN)
3�10 CQ,Gtt
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latIong is sufficient) 22.Cer ificatjon:
° P-71 St. 3" N Sz" 37 ' N 1 V" W
6.Is(are)the well(s) ermanent or Temporary gnature of Certified ell Contractor Dale
Bc signing this form,1 hereby?certify that the well(ti)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or h'o with 15A NCAC 02C.0100 or 1 JA NCAC 02C.0200 Well Convtruclion Standards and that a
/f 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.'b21 remarks section or on the hack of tris.farnt.
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 of well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:,3 2 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 12 30 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells lisi all depths ifdiffereni(example-3@100'and 2 a 100') construction t0 the following:
i
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lfupter level is above casins;,u.ve 1617 Mail Service Center,Raleigh,NC 27699-1617
1
11.Borehole diameter: 5 Z (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
t7�a Y� above, also submit one copy of this'form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method or test: 24c. For Water Supply& Injection 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 completion of well construction to the county health department of the county
where constructed. j
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources f Revised 2-22-2016