GW1-2021-04385_Well Construction - GW1_20210805

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
1.Well Contractor Information:
1 �
Taso h No � 14:WATER ZONES
Well Contractor Name FROM TO DESCRIP ION
i
1;a.-'a A ft. b ft.
ft. ft.
NC Well Contractor Certification Number I,' .{ D 15.OUTER.CASING(for.. ulti-cased wells OR LINER if a licable
ray Pot]JQi WJL)j ` I-(4,�{p Co. FROM TO - DIAMETER THICKNESS MA'rRRlei.
—� p ft. 5 tt. in. J v �
Company Name
3 5 3 Q��� � 16.INNER CASING OR TUBIN eothermalclaseddoo
2.Well Construction Permit#: FROM TO DIAMETER : THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State,Variance,etc.) it. It. tn.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public tt. fL' in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL R, in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT`
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD At AMOUNT
Non-Water Supply Well: Q ft. 0 ft r r
Monitoring pRecovery ft, fL
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK.(if applicable),
Aquifer Storage and Recovery .[3Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRiLLING LUG:attach additionaI sheets ifnecess .
Geothermal(Heating/CoolingReturn Other(explain under#21 Remarks FROM TO DESCRIPTTON color hardnes soil/rackin size,etc
v ft. Z rt. a ' ao i
4.Date Weli(s)Completed: Well ID# 2 fL
Sa.Well Location: Q ft. a 40 tt r OG
Facility/OwnnerName Facility ID#(ifapplicable) ft. fL
i ✓ Tkomas A(q(A ft. ft
Physical Address,City,and Zip ft. ft.
Flra h KI i 21:REMARKS . e7
County Parcel Identification No.(PIN) uQ"
5b:Latitude and longitude in degrees/minutes/seconds or decimal degrees:
fac►�at>an don
(if well field,one lat/long is sufficient) 22.C
cN W � ha/z/6.Is(are)the wells)(0Permanent or Temporary Signa re of Certifi d 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: OYes or eNo Taith 15A NCAC 02C.0100 or 15A NCAC 01C.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 ive/l 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 pagejto 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: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: l O ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2©100D construction to the following:
10.Static water level below top of casing: 10 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use" " 1617 Mail Service Center,Raleigh,NC 27699-1617
.t=
11.Borehole diameter: (in.) 24b.For Iniection 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: 0 ✓ construction to the following: N ,
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: L( 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: E71 O W 24c.For Water Supply&Iniection 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.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016