GW1-2021-02481_Well Construction - GW1_20210505

WELL 'ONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Cont rac informatl'gn:
�•" G✓. ✓ `c'� 14.WATER ZONES
—� r FROM TO DESCRIPTION
Well Contractor Name
y/, ,41 ft. r tt. s f�
NC Well Contr or Celific 'on Number a %' _ d J
r �Oq 15.OUTER CASING for multi cased,wells OR LINER(if applicable)
RFROM TO DIAMETER THICKNESS MATERIAL
1 !� 11. ft. in. J V L
CamparryNwrie�� a , ER CASING OR TUBING eothermal closed-loo2.Well Construction Permit#: ` t)�Il TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.C.'uunh,State, ariance,etc.) ft. ft. in.
3.Weil Use(check weft use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Q �nicipal/Public /1i S'ft. J'h ft. in.
Geothermal(iicatingiCooling Supply) f kt-wacmw Wales Supply(single) ft. it. �•
industriaVCommercial C3Rcsidentiai Water Supply(shared) 18.GROUT
I-lirrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non=Water Supply Well:
ft. ft.
Monitoring ORecovcry ft. ft.
injcction Well:
Aquifer Recharge dwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recove Salinity Barrier FROM TO MATERIAL EMPLACEMENTAItIMOD
Aquifer Test Stonnwater Drainage
Experimental Tee
y bsidence Control
Geothermal(Cl Loop) Tracer 20.DRILLING LOG attaen addfrional sheets/f ncocsaa
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM/ To DESCRIPTION mtor.hardness.sod'roek 'n size,eta)ft. a ft. 7 C�
2 ✓ ,•
4.Date Wells)Completed: " Well ID# ft. J ft.
tt. ft.
SIa.Well Location:
l U 1 1 � ft. 0 ft' C e, J P l�
�
,-acility/Owner Name Facility
(JD#(ifapplicable) ft- qG ft.J // ft.
ft. it.
Physical Address.Chitty,and Zip
I" A-'It l t 21.REMARKS
County
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certi7�:
N W 4
6.Is(are)the well(s) ermanent or OTemporary Signawre of Certified Well Contractor Date
�� By sibming this form,I hereby certifil that the iv ll(s)was(it-ere)constructed in accordance
7.Is this a repair to an existing well: QYes or [314 with 15.4 NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
I(this&a repair,fill out known well construction information and explain the nature of thr cap}q(rhis record has been provided to the well owner.
repair under#21 remarkv section or on the hack gftfiLv form. 23.Site diagram or additional well details:
S.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 1 GW-I is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL LNSTRUCTIONS
9.Total well depth below land surface: `� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2CfB.100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
I(narer level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (D (in.) 24b.For infection Wells: In addition to sending the form to the address in 24a
/� 1 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: A L.,,�Amk-1 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) s/ Method of test: 24c.For Water SUDDIV& Infection 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 t)Tc: h.� Amount: y Z completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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