GW1-2021-01873_Well Construction - GW1_20210503

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
?'04 14.WATER ZONES
FROM TO DESCRn'1TON
Well Contractor Name O 10(t ft
NC\VCLI Contractor Certification Number tc,OUTER CASING for multi-cased wells)OR;Li1VFR(it soulicable)
FROM I TO I D TER 7•tOCKNESS MATERIAL
rG Q L J' D ft. ( ft. in. " f t a10.
Company Nat �� O•� 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: ` FROM To DIAMETER MATERIAL
THICKNESS
O ft. a f ft in. C
List all applicable well construction permits(i.e.U1C,County,State, Parlance,etc.) 1
ft. tt. in.
3.Well Use(check well use):
17,SCREEN
Water Supply Well: FROM To M DIAETER SLOT SIZE THICKNESS MATERIAL
epic„lti al ElMunicipaUPublic k. ft.
Geothermal(Heating/Coohng Supply) oResidential Water Supply(single) ft. ft. io•'
Industrial/Commercial Residential Water Supply(shared) 18:GROUT
I-11rrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft Zp ft Ld^ Af r t fi
Monitoring 1311ecovery ft. ft
Infection Well:
Aquifer Recharge oGroundwater Remediation
19.SAND/GRAVEL`PACK.(if a ltcable
Aquufer Storage and Recovery OSalinity Barrier I FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test C)Stormwater Drainage ft• ft.
Experimental Technology Subsidence Control ft, tt.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG:attach addiddnaI sheets if mcessa _.
FROM TO DESCRIPTION color,hardness,soll/rock n s etc.
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks 0 ft L ft0 ID ` I
4 d
4.Date Well(s)Completed: -2 v—a/Well ID# ft• (� ft.
ft. tt. /) r 0 G
5a.Well Location:
T(�r,G'c tt x 1olc�rs .�ft / as :tR i✓ -V
Facility/Owner Name Facility ID#(if applicable) ft. ft
/&t5 drtUi r IaKt «r ft. IL
ft. ft.
Physical Address City,and Zip ���� t '
I 21.REMARXS
County Parcel Identification No.(PIN) r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification: Q
N W
6.Is(are)the well(s)dPermanent or OTemporary Signature Certified-Well Date
By signing this form,I hereby certify that the wr1l(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or ibNo with ISA 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 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 tie 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: X SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: v 0 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'acid 2@100) construction to the following:
10.Static water level below top of casing: / (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use +' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In'addition to sending the form to the address in 24a
Lo-1 - above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,eta
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY
/^WELLS ONLY: . I 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) ri+ Method of test: D w 24c.For Water Supply&In'lection Wells: In addition to sending the form to
L L the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: T h Amount: / 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