GW1-2021-03174_Well Construction - GW1_20210625

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
i
1.Well gntr cto Informn:
�� 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft ft
ft, fL
NC Well Con ctor Certification Number 15.OUTER CASING for male cased wells OR LINER if a 'cable
��( ,` ( FROM TO IETER THICKNESS MATERIAL
Company Name 16.INNER CASING OR TUBINvG eothermal closed400
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits ti.e.UIC,County,State, Variance,etc.) it. ft. in.
3.Well Use(check well use): ft. IL in.
17.SCREEN
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public t. Oft- in.,, C! S-
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
IITI ation FROM TO MATERIAL IEMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring Recovery ft. ft.
Injection Well: ft. it.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
r 6 % . d✓/
Aquifer Test DStormwater Drainage G ft. p
Experimental Technology OSubsidcnce Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heatin Coolin Rettun) Other(explain under#21 Remarks) FROM TO DESCRIPTION color hardness.softeck in s' etc.)
ft
1�"Nj(� / it. . 70 �/
4.Date Well(s)Completed: iJ Well ID# L/ ft' ft' t_/4
Sa.Well Location: �• ft• L/6
4 rt. v; rt. G 1�
Facility/Owner Name Q�/� ,^` �[�FacilityyIID#(ifa-pppliic/a�bic) ft' �t� ft'
W I C��d W I (V 11 1'� .'.1 u i V V t V! '
ft. ` ft. V ` UQ, ,
Physical Address,City,and Zip U
0 co 21.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IatAong is sufficient) 22.Certification:
N fir► ) 0 1
-6.Is(are)the well(s) (Permanent or DTemporary, Signature of Certified Well Contractor Date
By signing this form,I hereby certhl that the xell(s)was(were)constructed in accordance
7.Is this a repair to no existing well: QYes or - No with I5A NCAC 01C.0100 or 1 SA NCAC 02C.0200 Well Construction Standardv and that u
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
constriction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: / SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /JJ (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depdts if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: t% (it•) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I,
11.Borehole diameter:_ C _(in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
f above, also submit one copy of thI s form within 30 days of completion of well
12.Well construction method: /n✓C a lef 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: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) u Method of test: �t / 24c.For Water SuDDIy&Injection 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: Amount: '2 u Zy Z completion of well construction to the county health department of the county
where constructed.
4,
Form GW-I-_ North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016