GW1-2021-04386_Well Construction - GW1_20210805

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: i
1.Well Contractor Information:
14.WATER TONES.
Well Contractor Name FROM TO DESCRIPTION
ft. `3(b ft.
ft. ft
aUl A v -t
NC Well
tt Contractor Certification Number I� n 15.OUTER CASING for multi-cased,wells OR LINERWADI)licable)
/-w rn J bale
, .I I� .l Pam
( „1 FROM TO DIAMETER TffiCKNFSS MATERW
man IM1 ! 1n W {V r, L/jJ ft. ov ft. in. a�
Company Name r
�� �� I 1 ..INNER CASING OR TUBING 'eotherfnal closed,lootil
2.Well Construction Permit#: i+e FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County.Stale, Variance,etc.) tt• ft• in.
3.Well Use(check well use): ft. ft. I in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural nIylunicipal/Public ft. ft.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT TROD&AMOUNT
Non-Water Supply Well: ft. ft tte �.
Monitoring Recovery ft. ft
Injection Well: ft ft
Aquifer Recharge Groundwater Remediation
19..SAND/GRAVELP.ACK (f Ilcable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology J3 Subsidence Control
Geothermal(Closed Loop) Tracer 20:DRILLING LOG attach additional sheets if.necess
Geothermal(HeatinglCooling Return) ClOther(explain under#21 Remarks) I FROM TO DESCRIPTION(cotoA hardness sail/rack 47c,grain siM etc
ft. a It.
Iwo,
4.Date Well(s)Completed:Jiaft 91 Well ID# 1 R• ft•
5a.Well Location: ft a d tt• �m e,
e r 6 I le J
Facili t/Owner Name Facility ID#(if applicable)A' ft ft
(
I 1 � RURi ��IVe rJ SAY7r1u Rope 'V ` ft. ft
Physic13
al Add,�re(sss,City,and Zip
!—'—`7i1 t�I j 21.REMARKS
County Parcel Identification No.(PIN) riled
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t10n Pro 11
(ifwell field,one]at/long is sufficient) 22.C •fieation: 0
i
N W �zli 7 - Z�-�l
6.Is(are)the well(s)dpermanent or Temporary 0111inte of Certffiedfifbil Contractor 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: []Yes or flJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ijthis 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 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 I
9.Total well depth below land surface: -w (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di,(jerent(example-3@200'and 2@1001 constriction to the following:
10.Static water level below top of casing: 2 (ft.) Division of Water Resources,Information Processing Unit,
Ijwater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: (in.) 24b.For Infection 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: f® ✓� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'enter,Raleigh,NC 27699-1636
13s.Yield(gpm) J Method of test: ©� 24c.For Water Supply&Infection 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 Resource' Revised 2-22-2016