GW1-2021-03157_Well Construction - GW1_20210625

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1�Wetl Contractor I��nfo ti n:pprma r
14'WATER'ZONES.--
v FROM TO DESCRIPTION
Well Contractor Name
�t lbo�, UT � � ft.
NC Well Contractor Certification Number .15.'.OUTER CASING for molt[-cisedwella ORl'M'kl df`" bte x'
UL/l rn FROM To DIAMETER 7MCENESS M�ATFdWL
Company Named & b Z & G ra /O C70 /✓.AJ 7$
'1&INNER CASiWOR TUBING thermil dosed r :: -1k 's
2.Well Construction Permit#: ,)l f— FROM To DUMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): fL fL in.
l
ater SuPPh Well: '1ZSCREEN 7777
FROM TO DiAMEPER SLOT SIZE THICSNF�S MATPdUAL
Agricultural �MunicipaUPublic ft g in-
Geothermal(Heating/Cooling Supply) &Residential Water Supply(single) R & in,
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irri ation FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
on-Water Supply Well: ft '2_0ft 0 U DU(Monitoring Recovery & &
jection Well: R ft.
Aquifer Recharge [)Groundwater Remediation
19 SAND/GRAVEL PACK"ita 7icabli .
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT MM0D
Aquifer Test []Stormwater Drainage R ft
Experimental Technology Subsidence Control ft &
Geothermal(Closed Loop) Tracer 20.DRILI ING LOG attach add,aouii iheetsif nieces
Geothermal Heating/Cooling Return i Other(explain under#21 Remarks) PRoM TO DESCRD'1TON error,hardness eoi0ree§ sde,Nc
o ft. 2/0 & 544
G/a
4.Date Well(s)Completed: 2 2 Well ID# q0ft 'Zo
5a.Well Location: i R & s"
UI(,R f (JCh k ft� 1 I
Facility/Owner Name Facility ID#(ifapplicable) fL ft. 1Zjt
Zeb e �n r�Pd.f�nl)U�' ,t. ft. �►ts�;1;,�;�'� �o�,;rioi►
Physical Address,City,and zip ft. ft.
/21:REMARIcs_:<
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreestminutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W � 6 - !!l7-1
6.Is(are)the well(s)15Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or [3No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this 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 farm.
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 1 GW-1 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: d� (f4) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@2000''and 2@100') construction to the following:
lf
f Static water level below top of casing: 3 y (ft) Division of Water Resces,Information Processing Unit,
waterleve!is above casing,use + 1617 Mail Service Ceournter,Raleigh,NC 27699-1617
11.Borehole diameter: (in) 24b.For Infection Wells: to additii nto sending the form to the address in 24a
above,also submit one copy of this wifl»n 30 days of completion of well
12.Well construction method: a�� I form
(i.e.auger,rotary,cable,direct push,etc.)
construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: Q/ 1636 Mail Service Center,Raleigh,NC 276"-1636
13a.Yield(gpm) Method of test: 24c.For Water SuoDly&Infection 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: / completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016