GW1-2021-03518_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
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1'� /TC-OV � y — 14-WATER'ZONES`
FROM TO DESCRIPTION
Well Contractor Name 2�21 ft V rt& O
a � f
NC Well Contractor Certification Number , r eSSinc�Un`t
ti DCv ,.:15-OUTER CASING'formulti-eased wells OR:LINER'tf a `' bk = -
( � rr�1� ���1 ,r°�.�y�" D`'Jr� Cec�-On Fao TO D tfficlavFss MATEHAL
IJIN►/l� l ji(J t f ft io I
Company Name
{y. f�I �s., //�(� 16.INNER CASING";OR-TUBING. �"tbermald' ,.
2.Well Construction Permit#: ✓a I- ooc)3 " !J FROM To DIAMETER TEUCENES MATEarAI.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL ft. 1n.
3.Well Use(check well use): fL fL in.
Water Supply Well: 17.SCREEN'
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL~
Agricultural [3MunicipaVPublic 0 a. ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft. in,
industrial/Commercial Residential Water Supply(shared)
;IS:GROUT
711rrigation FROM TO MATERIAL EMPLACEMENT MXMOD&AMOUNT
Non-Water Supply Well: & aU ft )e U Aorvol
Monitoring p Recovery fl. ft
Injection Well: ft. ft
Aquifer Recharge Groundwater Remediation
I9 SAND/GRAVEL PACK of Sibilivable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERL41, I EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer ;10.DRILLING LOG'attach additidail;stieets if recess
Geothermal Heating/Cooling Return Other(explain under#21 Remarks) FROM To DESC MEO.h(color.hardness,soivrock type,grain size,etc
f ft tt V J QI I
4.Date Well(s)Completed: aAy" 1 Well ID# k a O fL
5a.Well Location: ()& yO & -5ci T
G h0o 1)f co hs�r� +,oV� S-C, ft ft
Facility/Owner Name Facility ID#(ifapplicable) ft ft
6�N s Yl\ 1 Pift. ft
Physical�Address,`City,and Zip ft &
REAIARKS n
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient)
22.Certification:
N "t
6.Is(are)the wells) Permanent or OTernporary Signature ofCertified Well Con or Date
By signing this fonn,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Slandards 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: _ d if L/ (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifelifferent(example-3@200'annd 2@100') construction t0 the following:
10.Static water level below top of casing: 01-u (ft) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use^+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
p.Well construction method: Gf, above,also submit one copy of this`form within 30 days of completion of well
7
(i.. construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cen`ter,Raleigh,NC 27699-1636
13s.Yield(gpm) �a Method of test o
10 L✓ 24c.For Water SuDly&Injection 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: l 7 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 j Revised 2-22-2016