GW1-2021-03484_Well Construction - GW1_20210607

\ tint orm_
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
S\ 044 14.WATER ZONES .
FROM TO DESCRIPTION
WellConuactorName ZQ fL 2 It !✓�
q36r4 ? 2021 2 2�
NC Well Contractor Certification Number `;,15.OUTER CASING for mul ed wells OR LINER rf
{ Y,,.. ;.,y,��CO'GG�`s'')vlo U`I 11 FROM TO DIAMETER THICK NESSUafe2 MATERIAL
/\ i, t,•� l„1 n +( ft.
8� h 6 in. , I U� Ga (n
Co y Name IDV 1 5 :^
I 16.INNER CASING OR TUBING ,thermal elesed400
2.Well Construction Permit#: FROM TO DIAMEI'Edt THICKNESS MATERLII.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. ia'
3.Well Use(check well use): ft. ft. fin.
Water Supply Well: 17.SCREEN -...
FROM TO DIAMETER SLOT SUM THICKNESS MATERIAL.
Agricultural [3Municipal/Public 0 ft, ft. in.
Geothermal(Heating/Cooling Supply) ffK-idential Water Supply(single) & ft. in.
Industrial/Commercial DResidential Water Supply(shared)
aJ&GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0ft. �'o & Plok !/ da
Monitoring Recovery fL &
Injection Well:
ft. ft
Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL PACK Ofa"ticable .
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL: EMPLACEMENT METHOD
Aquifer Test C)Stormwater Drainage fL ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necess
Geothermal(Hearin Cooling Retum) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock sae,etc
- & 6 o & Sal, a.
4.Date Well(s)Completed: �z� Well ID# & Z fL S
5a.Well Location:
oo Jcation: ft.- ft.
6, 1 ay i S ft. ft.
Facilityy/7Owwner Nam/eJ Facility ID#(if applicable) fL ft.
5 )T� H/nna,+ - �Qof40(\ �(�, <o �Ma a n
Physical Address,City,and Zip J ft. ft.
�n�nn51 ✓� 21'RENIARKS.
County Parcel Identification No.(PIN) d / c
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one laUlong is sufficient) 22.Certifica'on:
N WA
6.Is(are)the well(s)f oermanent or Temporary Sigrature of ra Well Contractor Dfite
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 6NO with 15A NCAC 01C.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 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: 7q5 00 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'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use + 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
`, above,also submit one copy of thisform within 30 days of completion of well
12.Well construction method: a f- 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(gpm) Method of test: 24c.For Water Sunvly&Iniectio We11s: In addition to sending the form to
j� the address(es) above, also submit!one copy of this form within 30 days of
13b.Disinfection type: G I 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