GW1-2021-01771_Well Construction - GW1_20210430

WELL CONSTRUCTION RECORD(GW-1) For Intern Use al Only: Print Form
I.Well Contractor Information: i
j.1/1J L--/ e W tJ 14.WATER ZONES 1 4
Well Contractor Name
FROM TO DESCRIPTIO
NC Well Contractor Certification Number 0 IL
S/ S/ 15.OUTER CASING for rttulti-easediweils OR LINER if a licablc
aIt�l 'P !S we �I p��- t JL V2riJ,ce FROM TO DIAMETER TIiiCKNFSS MATERIAL
rL ft. u t!
Company Name 7 in. S G /d Y G
2.Well Construction Permit#: b t� G l)b t 3 16.INNER CASING 6R TUBING eothermal TnVk1-loo
�/ FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Yariance,etc.) M R. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM I TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public 0 k(L tl i OL_ in. SIN v/
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft, ft. in.
- IndustriaUCominercial Residential.Water Supply(shared) 13.GROUT
hri ation FROM TO NAMRIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: t ft fa Pw rkafr Q 4!2
Monitoring Recovery ft. ft.
Injection Wen-
ft. ft.
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery 19.SAND/GRAVEL PACK if a liable
q g rySalinityBarrier FROM TO I MATERIAL EMPLACEMENTMETHOD
Aquifer Test [)Stormwater Drainage P ft. . !f ft.
Experimental Technology Subsidence Control % fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets If necessary)
Geothemral(Hearin Cooling Retum Other(es lain under#21 Remarks) FROM TO DESCRIPTION color hardn soiUroek in sire,etc.
tL It.
'0 SOr
4.Date Well(s)Completed: �1-a'1 Wen IDq ft• ( !Q ft. q e G a
5a.Well Location: 10 fL / ft s 4 n4/
�2V9
t` Clew ems 13 ft' A 60 ft- -Rig, & a
Facility/Owner Name a Facility ID#(if applicable) tL q a h
Physical Addrgss,Ci and Z" /' p ft. fL
��eQ . t! C, ' �� 3►'! 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/rninutes/seconds or decimal degrees: Worrnation Processing Unit
(ifwell field,one IaUlong is sufficient) 22.Ce Cation: ' ,Sf3-I
6.Is(are)the well(s)xPermanent or Temporary Signatire of Certified Well'Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: 21yes or []No 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 construe on 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 Wens 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: ® - � (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list al/depths if different(example-3Qa 200'and 2@100) construction to the following:
10.Static water level below top of casing:_ �I ft
( ) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: tinA 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: qr above,also submit one copy of this form within 30 days of completion of well
i ll foowng:
(i.e.auger,rotary,cable,direct push,etc,) construction to the �
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLr�Y WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 4' Method of test: G''T 24c.For Water Supply&Infection Wens: In addition to sending the form to
r the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Ci OPt fl Amount:_ 3 �k Ie 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 Revise:2-'n-2016

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