GW1-2021-03187_Well Construction - GW1_20210625

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
�artieS s101(+4
14:WATER ZONES
FROM TO DESCRIPTION
"'sll Contractor Name
W4?�- A I2: ft o. Sari Clay
ft. ft.
NC Well Contractor Certification Number /,n 15.OUTER CASING for multi-cased wells OR LINER if a licsble
CaSNA k— N I'll("y FROM tE TO DIAMETER in. THICIG�tESS MATEMAL
Company Name 16 INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) ft fL in.
3.Well Use(check well use): M ft. in
Water Supply Well: 11 SCREEN
FROM TO DIAMETER SLOT SIZE THICICCNESS MATERIAL
❑Agricultural ❑Municipal/Public I�' ft. V, ft. /It m. ,0'�/D SG+t y� PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) it. ft. in.
(/
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GROUT i
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Nf-Water Supply Well: fa ft.
BfMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
-19.SAND/GRAVEL PACK Of applicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage /3t 1t. aQ ft
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILL G LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soilfrock in size etc.
❑Geothermal(Heating/Cooling Return) ❑Other("plain under#21 Remarks)
D - It. , ILG i
4.Date Well(s)Completed: �� ( We11ID# Af9I0�I' D I //' fL ' ft. ,it•0—C/a
fL ft.
5a.Well Location:
0 rid 1/ ft. M
Facility/Owner Name Facility ID#(if applicable) M FL
015 Na41'ddal ad&W AD. 5af,1;g*••✓L M ft 1 1 22
Physical Address,City,and Zip ft. M j1111
&owe(4 Ybq oby 21 REMARKS:. XtloYli, y
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat11ong is sufficient) 22.Certification:
3!5. 6g4goWy N -1r19, 5aag3h9 W
6.Is(are)the well(s): ❑Permanent or !D'I'emporary Signature of ified 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 o 15A NCAC 02C.0100 or 15A NCAC 02C.0200 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 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 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: 24.SUBMITTAL INSTRUCTIONS
t
9.Total well depth below land surface: es2 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2@100)
f 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Z (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
YII 24b.For Infection Wells: Copy.to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
i
12.Well construction method: Sd n t�- 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
.JR 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:
I '
I
13b.Disinfection type: Amount: '
P
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018