GW1-2021-02659_Well Construction - GW1_20210620

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Infor ation:
AOVA OG I 14.WATER ZONES
Well Contractor Na FROM TO DESCRIPTION
Name fL ft.
2 y ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for ma)tl cased wells OR LINER if a ltcable)
I,I 1 iL '
/� W / Ti �, FROM TO
p� DIAMETER THICKNESS MATERIAL
VV 1 W WW ft.
Company Nine / ',f / 16.INNER CASING OR TUBING(geothermal closed-loom
2.Well Construction Permit#: (1 Vy D{p D p�/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,Coun)',State,Variance,etc.) 0 ft. / 2O ft. in. ✓G
3.Well Use(check well use): ft. { ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural P4unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft. in.
Industrial/Commercial Residential Water Supply(shared) 19.GROUT
-)Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well.
Monitoring Recovery
Injection Well: ft. tt.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a Ncable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. I ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if aecessa
Geothermal(Heating/Cooling Return) rJOthLr(explain under#21 Remarks) FROM ft, TO DESCRIPTION color,hardness,sontrotk type,grain size etc.)
ft.
4.Date Well(s)Completed: 5 " )' Well ID# ft. ft.
ft. ft.
Sa.Welly:ocation: I 1 i,�
IAJ t(+I A WI 6 h i1S1��i ft. ft. J U I V
Facility/Owner Name Facility ID#(if applicable) ft. ft sma u01)
(A Ga W I KA- ft. ft. �' QVVR Sect on
Physical Address,City,and Zip ( ft. ft.
Ale t ,] 21.REMARKS
oanty Parcel Identification No.(PIN) IYi 4
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(if well field,one Iat/long is sufficient) 22.Cer' tion'
N W
6.Is(are)the well(s)[3Permanent or 0 emporary tgna re f rtifie d Well. tractor Date J
B}'s gning this form,I herelry cert that the 11(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or [DNo with 15A NCAC 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
If this 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ltf
SUBMITTAL INSTRUCTIONS
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 if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (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: _(in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: �
� G� above, also submit one copy of this form within 30 days of completion of well
•—�(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: d 24c.For Water Supply& 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 type: •l Amount: 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