GW1-2021-03517_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well'Ctintracto�rr Information: r
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
�- ��N 2021 ft 0 it. o
jt ft %
NC Well Contractor Cemficarion Number riCC SSin�U 15.OUTER CASING for muld-cased wells OR LINER 's llcable
1�'R ss'- ^vn FROM TO DIAMETER THICKNESS MATERIAL
Well J . I '�t f V.
TT ft. ! 1n.
Company Name
e 16.INNEit CASING OR TUIiTNG 'eotbermal dosed-loop).�
2.Well Construction Permit#: d 0 FROM TO DIAMETER THICKNESS ATERIAL
List all applicable well construction permits(i.e.UIC,Count),,State,Variance,etc.) % & in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 11.SCREEN:
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
Agricultural unicipal/Public ft ft. In.
Geothermal(Heating/Cooling Supply) gResidential Water Supply(single) ft. fL in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
11'rt ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
ft , it.
-hied AA h !JCAIT�k
.Monitoring Recovery ft. ft
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.8AND/G12AYF.I:PACK If applicable)
Aquifer Storage and Recovery 13Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStonnwater Drainage
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if neeessa
Geothermal(Heatin Conlin Return) Other(explain under#21 Remarks FROM TO DESCRiMON color hardness,soil/rock in etc
6 ft. ft. SO
4.Date Well(s)Completed: 9-9)Well ID# z ft. 30 ft 4
Sa.Well Location: O n• (� ft• �� y-O G
Th(xt Sz a( 61�rs ft ft
Facility/Owner Name rd p Facility ID#(if applicable) ft. ft.
v �� ���howl . ZeG tJph, A7517
Physical Address,City,and Zip ft. ft.
A f g a 7,1 rQ d g7 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Cer Ieation- I
N W
6.Is(are)the well(s)dermanent or Temporary Si of Certified ell 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: [3Yes or EfNo 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 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
constructign,only I GW-1 is needed, Indicate TOTAL NUMBER of wells construction details, You may also attach additional pages if necessary.
drilled: 1 SUBMITTAL INSTRUCTIONS;
9.Total well depth below land surface: 160 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d fferent(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: 2a (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Inlecdon 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: ro-fg vY 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 Suoaly&Injection Wells: In addition to sending the form to
j, I the address(es) above, also submit I one copy of this form within 30 days of
13b.Disinfection type: f -t Amount: Z !� completion of well construction to the county health department of the county
where constructed.
Forth GW-1 North Carolina Department of Environmental Quality-Division of Water Resource's Revised 2-22-2016
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