GW1-2021-03182_Well Construction - GW1_20210625

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: p
1.Well Contractor Information:
JA'n►o 5AMA-1 14:WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft It.
o
fL IL
NC Well Contractor Certification Number IS.OUTER'CASING for multi-eased:wells OR LINER rf a licable
�^^/GA ��t i Yl A FROM TO DIAMETER THICKNESS MATERIAL
ft ft in.
Company Name
16.INNER CASING OR TUBING eothermal:closed4do
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. It. in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: _:FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
❑Agricultural ❑Municipal/Public �(t.• O`tt I' in. d S� 'to pile-
v
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft
❑Industrial/Commercial ❑Residential Water Supply(shared) 19,GROUT
❑h'ri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
NoM-Water Supply Well: ft ft.
onitoring ❑Recovery ft. ft.
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
1%SAND/GRAVEL'PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage A3t it h ' ftCA G ' (r-h- / .A, 6�PdVr
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20,DRILLING LOG.attach additional sheets if necessary).
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardne soil/rock type,grain size,etc
D ft 1S' ft
4.Date Well(s)Completed: 'q'11 Well ID# �IOC f"G3 IS, ft y0• IL c4C
5a.Well Location: tt ft.
US. Arm!l ft ft.
racility/Owner Name Facility lD#(if applicable) ft ft
�( �1/al+'s,noi/ GAur� �.D• Sall ary 'n/C- ft. rt. r 021
Physical Address,City,and Zip ft tt 1}j1
3LREMARKS �• fy s
1LDu�ah �(ba Dby If
rtti� t,. � .`
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
X, &Y7 317 o N -$D. .San M9 W
6.Is(are)the well(s): ❑Permanent or Amporary Signature o ertified Well Contractor, Date
�� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or $14o 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the;well owner.
repair under#21 remarks section or on the back ojthis 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: a 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: i (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ijdii ferent(example-3Q200'and 2Qa 100)
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' 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ijwater level is above casing,use"+"
10.Static water level below top of casing: 30 00 Information Processing Unit,1617� MSC,Raleigh,NC 27699-1617
b I t 11.Borehole diameter: (in.) 24b.For Injection Wells: Copy'to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: S D r1tlC— 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
"e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
OR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources es Revised 6-6-2018