GW1-2021-02267_Well Construction - GW1_20210514

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: Rs 41
a I U WATER ZONES
FROM
b! v r� FROM TO DESCRII'TION
Well Contractor Name �VI A l L i d ft { ft.
NC Well CnntractorCertificationNu ber r1^ij "0 Y 0
�£"' 11 is.OUTER CASING for multi-cased dvells OR,LINER tNER fif sun dcable
p. FROM TO DIAMETER THICKNESS MATERIAL
irt'LQ�K/ I, ft ft. ia. V L
Company Name 1
16.INNER CASING.OR TUBING eothermal closed-loop)
2.Well Construction Permit#: V .•i FROM TO DIAMETER TIIICKNES6 MATERIAL
in.
List all applicable well construction permits(i.e.VIC,County,State, Variance,etc.)
ft, t1, io.
3.Well Use(check well use):
17.5CREEN
Water Supply Well: FROM I TO DIAMETER SLOT SITE THICIINFSS MATERIAL
Agricultural unicipalftblic tt. fL in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft, in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft
Monitoring Recovery ft. ft
Injection Well: tt. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery 'Salinity Barrier FROM I TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. I
Experimental Technology E3Subsidence Control fL ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG`attach additional sheets:ifi:necessa
FROM TO DESCRIPTION(cold hardn saft"k rain sl eta
Geothermal(Hearin Coolin Return) Other(explain under#21 Remarks Q ft a ft. S O
4.Date Well(s)Completed: Well ID# ft. ft. G'
Sa.Well Location:
pft ft t ,t OCK
A { ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1 Q 5 P-o � ft. ft.f J ft. ft.
Physical Address,City,and Zip
AAV I _ 'V a ill C�, 21.ItEMAttKS
G rd
count, Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification- �1
N ` W
6.Is(are)the wells) Permanent or OTemporary Signature of 'red Well Conductor 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: [3Yes or 16No Kith 15A NCAC 02C.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 ropy 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 if necessary.F drilled: SUBMITTAL INSTRUCTIONS
(�¢�
9.Total well depth below land surface:� g y (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example•(3@200'and 2@100� construction to the following:
10.Static water level below top of casing: `� (ft) Division of Water Resources,Information Processing Unit,
#'water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniecdon Wells: In addition to sending the form to the address in 24a
,�y above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:_y'1� w Y 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 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Sunniv A Inlec`tion 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.
FW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016