GW1-2021-01095_Well Construction - GW1_20210305

WELL CONSTRUCTION RECORD GW-1 For InternalUse Only:
Y
1.Well Contractor Information:
F, J fa ;1-4co b ES
EE, FROM TO DFSCRH'TI0N
Well Contractor Nam�
^A ft. a Q fL i m
ft.
fL
NC Well Contractor Certification Number 15.`OUTER CASING or tnaltl�ased wells LINER(If a Iteable
FROM TO DIAMETER THIC"ESS MAL
l ft. la
Company Name
(� 16 INNER CASING OR TUBING' eotkermal closed-lob
2.Well Construction Permit#: V L16 T f) FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(I.e.ZTE,Coun)4 State,Variance,etc.) ft ft is
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER 1 SLOT SIZE THICK INESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. In.
❑Geothermal(Heating/Cooling Supply) EhTesidential Water Supply(single) % ft
❑lndustrial/Commeroial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT MITHOD&AMOUNT
Non-Water Supply Well: t5 ft a 0 R ( Pr-f 6 ttre
❑Monitoring ❑Recovery ft ft.
Injection Well:
ft -tt
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if'a ' ka file -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft fL
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach:addidoaal`sheets if necessa
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnm soil/cock type,grain size,etc
ft. fL G SV"
4.Date Well(s)Completed:r? Well 1D# p9 0 ft. 0 Cr t
5a.Well Location: o16 f DU fL SGr
f- I l er l,a d 1d It ers- f- I S f k
Facility/Owner Name / Facili 11(if applicable) ft fL)�) b C�1rG l,Grr� rY1 e-qI Lo % ft'
Physical Address,City,and Zip fL ft
a ,21.REMARKS .e
County Parcel Identification No.(PIN)
�& P c r P h Or'v'c S -e -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W &Z
6.Is(are)the well(s): Of�ermanent or ❑Temporary Signature of Certified well C &tractor Date �P
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 &N-0, 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known 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 an 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 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: I / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: "I (R') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 1@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)
/ Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: �G dr`f 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 where msta led
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR CCPCUA
13a.Yield(gpm) f Method of test:
Permit Program,1611 MSC,Raleigh;NC 27699-1611
13b.Disinfection type: I) Amount:
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018