GW1-2021-03190_Well Construction - GW1_20210625

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information::
1asne $,A1+h 14;WATER ZONES
_=Well Contractor Name FROM TO DESCRIPTION
ft &"L I
ft. ft.
NC Well Contractor Certification Number
p �.,,/I 15.OUTER CASING for multi-cased wells OR LINER if a livable
C.aS c,�de l�L f r�►q FROM TO DIAMETER !THICKNESS MATERIAL.
"4J C F/ , ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKINESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TRICKNESS MATERIAL
❑Agricultural ❑Municipal/Public t% ft tIP in.
a� 30• a o.dr sc44qd9 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GROUT
❑lrri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non- ater Supply Well: ft. ft.
onitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19,SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ' it 301 ft. 6-P a G yr f
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach.additio'nal sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/rock type,grain size etc
t 01 ft. �s. ft.
4.Date Well(s)Completed: a Well ID# r �-B� IS ft. ft. L(a
5a.Well Location: ft ft.
tU, Awy ft
Facility/Owner Name Facility ID#(if applicable) ft. ft. �' y&_ )6-
11 a i AM411god RD. Sa lifburt..�tlG fL ft.
Physical Address,City,and Zip ft. ft.
0 u 9a✓1 y �1 V`�7 21:REMAR1cs » « stn_ t
County Parcel Identification No.(PIN) dV u R 5G'".11011
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
3-<. 6`1 q.5,13 N -CO.S23 7o02- wffza;k=_ 4
6.Is(are)the well(s): E ermanent or ❑Temporary Signature of fie a 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: ❑Yes or P 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
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 if different(example-3Q200'and 2@100)
�1 r 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
't
624b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: S B n f,L 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
-`DR 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:
r
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourc`s Revised 6-6-2018