GW1-2021-03282_Well Construction - GW1_20210702

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: RECEIVE D F
AQ��_ 4 �>��,��
i 14.WATER ZONES ,
Well Contractor Name J U L 0 d ZOZ 1 FROM ft TO ft DESCRIPTION
ALI/ 8 a �2ds l m
NC Well Contractor Certification Number inform.3tion prO�SSIng U (;
tt. ft.
//�//'J�� ,,•,/ //�� plu"R Sed-on 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
ft. p l4 in. ���C oZ
Company Name
/� // q/ Q M.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:ol� 4- 7�O1Co %' / I FROM TO DIAMETER THICKNESS 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.
17.SCREEN
Water Supply Well:
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. fL in.
I
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. ih. I
!
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT f
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery 13 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.
Geothermal(Heating/Cooling Return)�i Other(explain under#21 Remarks) o ft. �5 ft.
4.Date Well(s)Completed:9! ' 7' d Well ID# uKft. �d 5 ft.
5a.Well Location: ft. ft.
�r�� Sm nth ft. rt.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
ft.
Z-aZ ZV ax-1Unl�x A )04tf 6410 ft.
Physical Address,City,and Zip SY/010_1 /-/a 2 77 ft. ft.
IJ�dx �r�_ �L- ���� 21.REMARKS
County /1 Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Cer' tion
6.Is(are)the well(s)OPermanent or 13Temporary Signatur of Certified Well Contractor Date
By signing this form,I hereby certify that the mdl(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or No with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information nd explain the nature of the copy of this record has been provided to the well owner.
repair under#11 remarkr 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 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: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200''an/d 2@@100') construction to the following:
10.Static water level below top of casing: �Y`v (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service;Center,Raleigh,NC 27699-1617
4
11.Borehole diameter: (in.) 24b.For Iniection 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
12.Well construction method: /l6 Cgic 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 m q / \ i(gp ) � Method of test: /�of OLt�¢J 24c.For Water SuDDIv& Iniection 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:�0 9 ZLQ 64. 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