GW1-2021-02615_Well Construction - GW1_20210620

WELL CONSTRUCTION RECORD(GWp For Internal Use Only:
1.Well Contractor Information: ^V`
l fd J.VVV l� 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ` 9
S$ 140 ft 10 fc
NC Well Contractor Certification Number
,+ is.OUTER CASING for mukitased wells OR LINER If a It-ble
5 L� i�^�n-�g �e` �__��J�`�O FROM TO DIAMETER THICIOVESS MATER L
a A '( 17�(' l ft. n/, ft. in. /6 1/t
Company Name 6. (.t!/ t�sf
G s 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: G ��l►� 7-1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.11/C,County,State.Variance,etc.J }-' ft. 5 0 ft. in. e/1_ 4 n u
3.Well Use(check well use): ft. ft. iFL 7��t `ti
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
• ❑Geothermal(Heating/Cooling Supply) /esidentiat Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
Oirrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 14ftQlft. SO ft r"nl V /'
75
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK it applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Storrnwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color, ardnws,soR/r«k rain size,etc.
A. ft wa tC
4.Date Well(s)Completed: Z/ Well ID# ft. ft Grow q 6 pi
59.Well Location: ft ft ( G K) -
Dan►C1 tc-r, l �✓� ft. ft. Tyk�k Rod fo
Facility/Owner Name \\ Facility IDN(if applicable) ft ft +o
ift-
Physical
q 1 51 W d tvb`,� 2 U , n���i�\1i{ �� ft
Address,City,and Zip ft. ft
Nq 1/_` 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certi ation•
N W
6.Is(are)the well(s):Xermanent or ❑Temporary Si of Certified Well Contractor Date
Ry si ing rhi.c farm,1 herehy certify that the weI/(s)was(were)rnnrtrucred in accordance with
7.Is this A repair to an existing well ❑Yes or /o I5A CAC 02C.0/00 or/5A NCAC 02C.0200 Wel!Construction Standards and chat a ropy
If this is a repair,fill out known well construction information aril eeplain the nanrre of the of t it record has been provided to the wet!owner
repair under 421 remarks.section or on 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: !(J (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dl�ereni(example-3@100'and 2@100')
of casing- 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top g (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use'-"
11.Borehole diameter: to (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Caber- 24c.For Water Su I and O en-Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environments t epartment o the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
!��13a.Yield(gpm) Method of test: 10 Permit Program, 1611 MSC,Raleigh,NC 27699-1611
jy y� n 1'�
13b.Disinfection type: l fd l'7 Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018