GW1-2021-05677_Well Construction - GW1_20210723

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
✓1 �b s` �� -14i WATER'ZONES _ x
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Well Contractor Name FROM TO DESCRIPTION
NC Well Contractor Certification Number / J ��t�ti OUTER CASING:for mWd cased wells OR:I INER tf:a bk
u a/ ro n �C 1.1 C c�t'l,}�f,`C„���'`'' oM To DIAMETER THICIGINFGS3 MATIIUAL
—`��2e, ft 3 7 ft. ' is /00 �6✓
Company Name
16.INNER CASIWG.Olt TUBING. 'thermral dosed �s
2.Well Construction Permit#: tT 6J 7 ~tom (�l FROM TO DIAMETER THICENEss MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft & 1n.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.'SCREEN.FROM TO DIAMETER SLOT SUM THICKNESS t MATERIAL
Agricultural [3MunicipaUPublic U ft ft in
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft in,
Industrial/Commercial Residential Water Supply(shared) ia.GROUT 4a cIrrigation FROM TO MATERIAL EMPPLACEMENT OD&AMOUNT
Non-Water Supply Well: O ft a(j ft Glt/'C
If
i
Monitoring [)Recovery ft ft J. e h
In
Well: "�"�
ft ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK tif a 7icable ,
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEM]M METHOD
Aquifer Test 13Stormwater Drainage f fL
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) OTracer 20.DR[i I ING LOG attach additional;shceis ifnecess
Geothermal(Heatin Cooling Return) 0 Other(explain under#21 Remarks) EOM To DESCRIPTION color,hardness sureek sae etc
0 ft- ft
4.Date Well(s)Completed: Well ID# 3 fL v ft C d 1
5a.Well Location: ILSQ & San
/rlq�he/ S0 fL OSr ° G nit�e
Facility/Owner Name Facility ID#(ifapplicable) ft ft.
ft ft
Physical Address,City,and Zip ft ft
k 21'REMARKS,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification
N W
6.Is(are)the well(s) Permanent or Temporary Signature ofCertifi d Well 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: ®Yes or E3<o with 15A NCAC 01C.0100 or 15A NCAC 02C.0100 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 ifnecessary.
drilled:
SUBMTTTAL INSTRUCTIONS
9.Total well depth below land surface: C (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiferent(example-3@200'anndd 2@100') construction t0 the following:
10.Static water level below top of casing: v fk
( ) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use•'+•II• 1617 Mail Service Center,Raleigh,NC 276"-1617
11.Borehole diameter: lD J(in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: G 1'(�-/�/ above,also submit one copy of this form within 30 days of completion of well
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 276"-1636
13a.Yield(gpm) Method of test /G 24c.For Water Sunoly&Infection 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: 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