GW1-2021-02262_Well Construction - GW1_20210514

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
tQ i 14•WATER ZONES
oA 1 FROM ft TO ft DESCRIPTION
m Well Contractor Na A n L
q�1Ay 1 "t L � 3
C�r�giC3�VYti ft. tt.
NC Well Contractor Certification Number NCO
t �it0 Er 1pC1 15.OUTER CASING formuld-cased wefts OR LINER if a licable
�CrriCilCT'3 y t, FROM I TO DIAMETER 1 THICKNESS MATERIAL
� raJ�Y� Paa�t- �a�� QumP v it. in.
Company Nami
p ft. G
D Q Q 16.INNER CASING OR TUB G eothermal;citisedaoo
2.Well Construction Permit#:41 3 O U i FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft• ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft ft, in.
Geothermal(Heating/Cooling Supply) [3Residential Water Supply(single) ft• ft. in,
Tndustrial/Commereial CIResidential Water Supply(shared)
18.GROUT
Irri ation FROM I TO MAT RU1L E14PLACEME METHOD&AMOUNT
Non-Water Supply Well:
Monitoring Recovery ft. ft. `s
Injection Well: it. fe
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if a_.Ilcitble
Aquifer Storage and Recovery Salinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets if necessa
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks V
T Z. ft• D CRC ON er h rdness soll/rock n sia etc.4.Date Well(s)Completed: ' Well EN 5a.Well Location: .Z 0ft. N Ah 4I- OGk
sc'* {- (tffW ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft•
l t 6 6crc.��n o e� ft. ft.
Physical Address, ft.
r,City,and Zip / Q
rr,VX Va ir1 I �P 21.REMARKS
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.Certification:
N wLtlp"'.J. --l� 3 -a
6.Is(are)the well(s) Permanent or Temporary Signature Certified Co ctor Date
By signing this form,1 hereby cer16 that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or dNNo Ivith 15A NCAC 01C.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 1 GW-1 is needed. Indicate TO' AL NUMBER of wells construction details. You may also'attach additional pages if necessary.
drilled: I / SUBMITTAL INSTRUCTIONS
^
9.Total well depth below land surface: eta o 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d8erent(example-3(a 200'and 2@100) construction to the following:
10.Static water level below top of casing: 0' (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection 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: rb"�Gild I construction to the following:
(Le.auger,rotary,cable,direct push,etc.) T
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: Q 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: N 24c.For Water Suanly&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: Amount: Z completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016