GW1-2021-02655_Well Construction - GW1_20210620

I I11 I 1 V/111
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ot6 D p a{' 14.WATER ZONES
OM Well Contractor Name TO DESCI UON
b ft.
VY1
d•�7 1 ��1� tQr�el�� ft. ft.
NC Well Contractor Certi catio¢Number �� �Q,G 15.OUTER CASING for multi-cased wells OR LINER if a (cable
I r nJ` r�� FROM TO D fETER THICKNESS MATERIAL
r b D t p R. ft. G/
Company Name \��
� O � 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction perntiis(i.e.WC,County,State, l'ariunce,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) et. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMEN METHOD&AMOUNT
Non-Water Supply Well: ft. /�b ft. I• ���V s
Monitoring ORecovery
Injection Well: —
ft. ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery E)Salinity Barrier FROM I TO MATERTAI. EMPLACENIFNT METHOD
Aquifer Test OStormwater Drainage
ft. ft.
Experimental Technology DSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling RetuReturn) TO DESCRIPTIONcola hardness soil/rocka nin size,etc.)
Other(explain under#21 Remarks) O FROMft. ft. 5
op
4.Date Well(s)Completed: Well ID# R• O ft.
Gn Well T �Qh� �,
tV� 71 `/ D,/�,1 rj7c
i �1n l V � A v
Facility/Owner Name Facility ID#(ifannlica le) ft. ft.
45 G(OQ 6 r ft. I ft. —
Phvsical Address.Citv.and Z / ft. ft.
1 �7 7 7 G 135 21.REbfA K 1 —
County Vl Parcel Identification No.(PIN) —
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees.
(ifwell field,one lat/long is sufficient) 22.C fication'
N W -7
6.Is(are)the well(s)permanent or OTemporary Sign re of Certified Well Contractor Date L
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well [3Yes or (6No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
tf9ne;�n.onn;. fill nut 4nn,.un,.mn.•nn�r.,,nnnn;„f vmnfinn nnAo.-nin;n rho—h—nftho copy o(this record has been provided to the well owner.
repair under#21 remarks section or on the back of thin Donn.
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
drilled: .:, , �......,,..,jv-^,•..•gv..jYyv .,,,..., SUBMITTAL INSTRUCTIONS
_._
' l'UIIJLI'LLel.lUil LU Li1C 1011UW1118:
10.Static water level below top of casing: a- (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,us "+ 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
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 0� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
13a.Yield(gpm) Method of test: OW 24c. For Water Supply BI Injection Wells: In addition to sending the form to
r1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: ` r 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