GW1-2021-01979_Well Construction - GW1_20210505

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Y ` FROM TO DESCRIPT ON
Well Contractor Name L �j {t, � ft. e�;
/-J J ft. ft. C 6 1
�"+iC Welt C ntractor Certification Numbe 15.OUTER CASING for multi cased wells OR LINER if a livable
FROM TO DIAMETER THItCKN'EISS MATERIAL
ft. �= ft. in.
Company Name 16.INNER CASING OR TUBING eothermat closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable uve11 construction permits(i.e. UIC,County,State. Variance,etc.)
ft. ft. in.
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in. (� X
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
Industrial/Commercial residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: CJ% ft. w) ft.
Monitoring ORecovery ft. ft.
Injection Well:
Aquifer RechargeGroundwate mediation
19.SAND/GRAVEL PACK(if a livable
Aquifer Storage and Re Very �Sa(i artier FROM TO MATERIAL EMPLACEMENT METHOD
a q
Aquifer Test I
water Drainage
Experimental Technology idence Control
Geothermal(Closed er 20.DRILLING LOG attach additional sheets if necessaFROM TO DESCRIPTION(color.hardness,soil/rmk e. rain sby,ere.Geothermal eating/Coolin Retur e aiw under#21 Remarks)
4.Date Well(s)Completed: Weil ID# -
JYA
5a.Well Location: �[j
ft. ft. f-
-acility/Owner Name Facility iD#(ifapplicable)
ol
ft. t p.
Physical Address,City,and Zip
\ t, 21.REMARKS m I
County Parcel Identification No.(PIN) r
PAA
2021
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification n vcrmot'on Processing Unit
N W �_l.
>f v��tion
Signature of ertifred Well Contractor Date
6.Is(are)the well(s)�rmanent or Temporary
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Dye or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
1j'this is a repair,fill out known well construction information and explain the nature gjthe
cony 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3(L200'and 2(a 100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
#water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
- �` J\ 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.) t
Division of Water Resources,Underground Injection Control Program,
I 9OR WATER SUPPLY WELLS ONLY_ 1636 Mail Service Center,Raleigh,NC 27699-1636
�.
13a.Yield(gym) (J/ Method of test: � 24c.For Water Supply&Infection Wells: in addition to sending the form to
' L the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection tJT►e � 1t1 Amount: `"l V completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016