GW1-2021-03180_Well Construction - GW1_20210625

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Wellll�Coonttrractor Information:
D JINNI couz 14.WATER ZONES
FROM TO DESCRIPTIO
Well Contractor Name�/
L/ ft. c i 'L i
NC WellContractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
COG
,e h^ Y� �_ FROM fl T�c1 ft. DiM1ETERin. T5CKNESSq- MATERIAL,
Company Name ` v r` 16.CiINNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,CounUt State,Variance,ere.) ft. ft. DIAMETER
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FR SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural mcipaVPublic �ft. Vft.
J in• v
c 4 Cz
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 111, ft. e C_— �-
Monitoring []Recovery ft, ft. C
injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ©IStonnwater Drainage v ft. G ` ft. T/%� ZS✓
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Retum) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,sailtrack type,gnin sae,etc.
ft. ft-
4.Date Well(s)Completed: "l.0 V ( Well ID# ft' C tt• G -
5a.Well Location: ft. 3 ft. e l
1N i�li �,vY► N�tl0u�ncJ�'y� ,�� ft. 3 ft.
t
Facility/Owner Name Facility 1D#(ifapplicable) tj ft" L rk
(�5� WU�klnty��� � • �tW1 U�� ( ft. � ft.
Physical Address,City,and Zip
21.REMARKS _onnfcO
�&
County Parcel Identification No.(PIN)
5b•Latitude and longitude in degrees/minutes/seconds or decimal degrees:
0f2wcclll field,one Iat/long is sufficient) 22.Certification:
W ��
6.Is(are)the well(s)(91P/Irmanent or DTemporary Signature of Certificd Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes Or �No with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fill out known well construction information and explain the nature ojthe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of[his 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 I GW-1 is needed. Indicate TOTAL NUMBER of welts construction details, You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: X.O (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdderent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: �.V (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+ 1617 Mad Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection 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
Irn
12.Well construction method: Y 1 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) Method of test: 24c.For Water Supply&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: NNW Amount: U 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