GW1-2021-02658_Well Construction - GW1_20210620

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
\ (/by N t 0011t 14.WATER ZONES
Well Contractor Name I FROM TO DESCRIPTION
•l Lino
it D ft. ft.
recessing
In)clrratton F' ft. ft.
NC Well Contractor Certificatio Number Q�NR se.jion 15.OUTER CASING for multi-cased wells OR LINER If a cable
�µ •� O I sP + n, FROM TO DIAMETER TRICKINESS MATERIAL
(� IN 0 ft. �( ft. in. u
Company Name /r 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: lJ/ - 6 OL� 'O - ay- FROM TO DIAMETER THICIQVESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. f61) ft. In. V
3.Well Use(check well use): ft. ZJ ft. In.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE TRICKINESS MATERIAL
Agricultural unicipal/Public ft, It. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) tt. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. D ft. hchivp ra vite
Monitoring ORecovery ft. ft.
Injection Well: -
ft. tt.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK ifapplicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stonmwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft. -
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets R necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soillrock rain size etc.
ft. 7- ft• O so
4.Date Well(s)Completed: J�1 Well ID# a
ft. ,!" ft.
5a.Well Loc lion: ` it. Ott. lr Q yl l ,� U
� GL
Facflilitty/C)_er Name Facility ID#(if applicable) ft• [t.
lot w tt J)dj I-a O V S 2.e Wo r)
Physical Address,City,and Zip ! 11L TobaLCo Rol W Jr.r,4''15 q 1
ft. ft.
WfA k p 21.REMARKS -
County Parcel Identification No.(PIN) I t w b0 16
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(ifwell field,one IaVlong is sufficient) 22. teation•
N W �� Q
6.Is(are)the well(s)dPermanent or OTemporary Sig of Certillell
ontractor Date
By signing this form,I hereby certify that the r,elli's)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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#21 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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I l SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: O {ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii Brent(example-3@200'and 21@1001 construction to the following:
10.Static water level below top of casing: U (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ll/ (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
t� above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: f b a r I 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: r 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) `O Method of test: r®� 24c. For Water Supply& Iniection 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: 1 Amount: 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