GW1-2021-05474_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
e)A n't 14.WATER'ZONES
Well Contractor Name FROM TO RMCRIPTION
o
NC Well Contractor Certification Number 5.-OUTER CASING for multi-cased OR LINER f kp�cable)--
CCA 4 e- I FROM TO D=118) THICKNESS MATERIAL
Company Name ft. (674-, in. I St>C---9, ,; -1 P V C
16.INNER CASUVG OR TUBING(ifedthi-- AvUsed-106�). -,i
2.Well Construction Permit#: a 0 Vo 10 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State. Variance,etc.) ft. ft. 1 1 i
n.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN.,',.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []M�un�iblic It. ft. hi
Geothermal(Heating/Cooling Supply) OlGidential Water Supply(single) ft. ft. W.
Industrial/Commercial [2Residential Water Supply(shared) :18.GROUT
711rrigation FROM TO TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: t7 1'. a0 ft- to-nC rz C's, (a so k)b
3Monitoring [3Recovery tt. & C1 to r,90.
Injection Well: ft. I
rlAquifer Recharge DGroundwater Remediation
19:S AND/G PAVE V-PAC.W(i C iiIii i I I J k b I j)- tr_t
Aquifer Storage and Recovery 13 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG jatthcbhdditiofiiWib6ets1f n6e6sa
lGeothermat(Heating/Cooling Return). E3Other(explain under#21 Remarks) FROM TO DES KI ON(color,hardness,soil/rock size,etc.)
4.Date Well(s)CompleteJ V
Well ID# -g,ft. ft- C-3
5a.Well Location: 5.ft. &50 ft.
�Pail 14 0 Cxt- 5+6ft-
Facility/Owner Name Facility ID (if applicable) ft. ft.
r,,4 1;%)
ft. ft.
i (YA rl
PhhiicaI Addres City'and Zip ft.
REMARKS
KS
e,, 'rS orb
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: IF
(if well field,one lattiong is sufficient) 22.C7eation:
I S ld--i ' 156�,/ N C6 a ID I C\ 3 (c) g W 4-1 5
6.1s(are)the well(S)OFermanent or E3Temporary Signature of Certified Well ContriKor Dati
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 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
construction,only I 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 ifdifferent(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 C enter,Raleigh,NC 27699-1617
11.Borehole diameter: 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: WIT-e--y— T
!fI— construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY,/WLLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I 13a.Yield(gpm) Method of test: 24c.For Water Supply&Iniection`'Wells: In addition to sending the form to
I
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 4-Tq Amount: completion of well construction to I the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2222016