GW1-2021-01007_Well Construction - GW1_20210419

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER-ZONES:
Well Contractor Name nFROM
TO DESCRIPTION
�f31` A ft. 2
NC Well Contractor Certification Number /�s PM
f CASING for multi*ased*0s OR LINER -a Usable?
TO DIAMETER TIUCICNESS /M�ATERW.
ft ft 6 im. �� Ga(va,"Le
Company Name
Z�O i\ 16.INNER CASING OR TUBING ebthermal`closed-1 `
2.Well Construction Permit#: lJ FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft in.
3.Well Use(check well use): ft ft in.
7.,SCREEN.
Water Supply Well:
FROM TO DIAMETER ' SLOT SIZE THICIQtlM MATERIAL
❑Agricultural ❑Municipal/Public ft [t. in.
❑Geothermal(Heating/Cooling Supply) adesidential Water Supply(single) ft. ft,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT ._
❑Irri ation ❑Wells>100,000 GPD FROM TO MATFRrer. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: it.
To It.
C7o fC f Wr
❑Monitoring ❑Recovery fL ft
Injection Well:
ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
,19:SANDIGRAVEL PACK`d:" ileable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage It. It.
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach'sulditional sheets if uecessa
OGeothermal Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color hardy soil/rock type,grain size,etc.)
O ft � ft G 1
4.Date Well(s)Completed: 2' Well ID# G ft /8 ft s fa ;e e. :
5a.Well Location: 1 p ft 26 J— f CJ
ft. ft. - 9
Facility/Owner Name Facility ID#(if applicable) ft. it. 511
to g-1gkW.t.( �rE`,. F�c��L�l,n�vn ft ft +3�i��
Physical Address,City,and Zip fL ft e i u
�aA i n 21.:RE3ARKS" `
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(long is sufficient) 22.Certiticati n:
N W
6.Is(are)the well(s): C3Permanent or ❑Temporary S' cure of Ccrtifi ell Contractor Da
By signing this form,I hereby certify that the well(s).was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 9(0 1 SA NCAC 02C.0100 or I5A NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,fill out brown well construction information and explain the nature of the of this 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
12
9.Total well depth below land surface: 1-65-- (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@1001
10.Static water level below top of casing: f E_J (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" )
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
/�
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: gd -L4 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing Ever 100.000 GPD:Copy to DWR,CCPCUA
// J5n�� Permit Program,1611 MSC,Raleigh,NC 27699-16 1 1
13a.Yield(gpm) l0 Method of test:
13b.Disinfection type: 7 Amount: /
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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