GW1-2021-03456_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
1 h CO "' .s:
14 VNpT&R'ZONES_
FROM TO DESCRIPTION
Well Contractor Name /
NC Well Contractor Certification Number VI}l,ccessk" ';-15.OUTER CASING for multi used well) ORIINER'lfai"
FROM TO DL►MF.TPdt . THICKNESS MATERIAL
y is
Company Name
70 / 16:INNERCASING OR TUBING. thermal eliised �i i a
2.Well Construction Permit#: b FROM TO DIAMETER I MUCKNESSLMATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc) ft ft in.
3.Well Use(check well use): ft ft m•
Water Supply Well: 17.SCREEN :FROM TO DLR,METER SLOT SIZE I THIC1QWM MATERIAL
Agricultural [3MunicipaVPublic 0 ft ft in
Geothermal(Heating/Cooling Supply) residential Water Supply(single)
ft R in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Geothermal
lion FROM TO MATJERI" EMPLACEMENT OD&AMOUNT
Non-Water Supply Well: ft 1 ft�-�fQ 4 Ure
Monitoring 13Recovery ft ft
Injection Well:
Aquifer Recharge [3Groundwater Remediation ft ft
w„
"19.SAND/GRAVEL PACK tfa "lieabte
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERI EMPLACEMENT MEMOD
Aquifer Test []Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer 20 DRILLING:LDG sttach additionil'sheeisif,neee)s
Geothermal(Heating/Cooling Return Other(e lain under#2l Remarks) FROM To DFSCRIMON color,h.ran soitttock site,etc.
6 ft ft G 5 D'•t
4.Date Well(s)Completed,• t�r Well ID# ft. d O ft G
59.�Well
_Location: ft fi ft S'Gn
Facility/Owner Name Facility D#(if applicable) ft• ft
& f
Physical
Address;,City,and Zip ft. ft
rr4h 21.""REMARKS =f(;
County Parcel Identification No.(PIN) iPe 6 4r P �•r fe O
5b.Latitude and longitude in degrees/minuteYseconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N
6.Is(are)the well(s)J�ermenent or OTemporary Signature ofCerdfied Well Co ctar 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: 13Yes or 6:7t�o 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 thisform.
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: 10 L/ (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiierent(example-3@200'and 2@100') construction to the following:
/fwater level is above casing,use
f Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
"+"r_ 1617 Mail Service Cente� r,Raleigh,NC 27699-1617
11.Borehole diameter: `� (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12 Well construction method: 0G/t above,also submit one copy of this;form within 30 days of completion of well
(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:
1636 Mail Service Center,Raleigh,NC 27699-1636
i
139.Yield(gpm) Method of test: �6 Le� 24c.For Water SuDDIv&Injection Wells: In addition to sending the form to
{ the address(es) above, also submitlorie 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22=2016