GW1-2021-01857_Well Construction - GW1_20210503

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
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1�.QWell Contractor Information:
z—n 5�e 14.WATER ZONES B
Well ConWAC&Name FROM TO DESCREnWN
�I i ai o IL ��o �p
NC Well Contractor Certification Number 1&OUTER CASING r meltf eased wells OR LIIVSIt der e
FROM
MVERLAL
.t ft. � ft. D `a' ����
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Company Name 11
3 I 1 I lti.INNER CASING OR TUBDYG closed-too
2.Well Construction Permit#: FROM To DIAMETER I THItKNM MATEsreL
List all applicable well cant--ion permits CLe.MC.Conmty.fie,Variance.etc.) ft• R t in.
3.Well Use(check well use): ft.
Water Supply Well: 17.SCREEN
FROM TO DI NWEER SLOT suz MCKNI 3 MATELUAL
Agricultural QMunicipaUPublic 0 ft. ft. m
- Geothermal(11cating(Cooling Supply) JoResidentud Water Supply(single) IL ft. tar
IndustriaVCommercial Residential Water Supply(shared) 18.:GROIN f
on FROM I TO MATERIAL K"MCff#UMMETHOD&AMOU"
Non-Water Supply Well: ft• �7 ft• �µ t
Monitoring [Recovery 7J ft. a 0 fL
Injection Well:
ft. It
Recharge 043roundwater Remediation
19.SAND/GRAVEL PACK if bk
Qtiifer Storage and Recovery Salinity Barrier FROM TO MATERIAL 13MI.ACEPAU T METHOD
3Aquifer Test �Stormw�ater Drainage ft
_ Experimental Technology Dsubsidence Control ft-
RGeothermal(Closed Loop) DTracer 2U.DRIIJMG LOG attach additional sbeets K
Geothermal(HeatiiWC-1mg Rettmm) Other(ex #2 plain under 1 Remarlrs) FROM To D ox color; sa0noek era etc
o IL ft. Sf
4.Date Wells)Completed:`'� 018 a Well 1D# 3((I 'S ft. ft.
5a.Well Location: ft. ft.
ft.
Facility/Ow>xaName FacilitylD#(ifapplicable) ft. ft. I `. t L.
Physical Address,City,and Zip
G f N 2L REMARKS
.s..L.:
County Pared Identification No.(P"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Wong is sufficient) 22.Certification:
3 1-7 344 N r i5. 4 �, (0 6-1 W �— - ©4 a.1
6.Is(are)the well(s)OPermanent or Temporary Signature of ed We Contractor Q Date
By signing this form,I hereby certify that the we (s)was(were)constructed in accordance
7.Is this a repair to an eristing well: QYes or O)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
ff this is a reparr,fill out brown well construction information and explain the naftre ofthe copy of this record has been provided to the well owner.
repair rider#21 remarks section or on the back ofthis 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: S^ (R-) 24a. For All Wells: Submit this 1form within 30 days of completion of well
For multiple wells/at all depths rfdii ferent(=wnple-3@200 and 2@100) construction to the following
10.Static water level below top of casing: (fi:) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing use-+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (fD.) 241L For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: tT/ 0 �4 above,also submit me copy of this form within 30 days of completion of well
construction to the following.
(i-c-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 27699-1636
i
13a.Yield(gpm) Method of test 0i q 24-For Water Supply&Injection!Wells: In addition to sending the form to
the address(-) above, also submit one copy of this fora within 30 days of
13b.Disinfection type:/1 f:L Amount: ::�X0 2- completion of well construction to'°the county health department of the county
where constructed
Form GW-1 North Carolina Department ofEuvironmental Quality-Division of Water Resources I Revised 2.22-2016