GW1-2021-05505_Well Construction - GW1_20210805

I I It it r V(I IF..
T CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contra
Rctor Information: t
�WSt P% POtD[e 14.WATER ZONES f
Well Contractor Name FROM TO I DESCREPTION
ft. ft.
NC Well Contractor Cerred?
tion Number r 15.OUTER CASING for multi-cased wells OR I JNER if livable
��rr d t Gl Ili
/�^ FROM TO DIAMETER THICKNESS MATERIAL
1 (� Ii. 3 fL in. N 46 G,
Company Name `
' I ( iti.INNER CASING OR TUBING eother el closed-loo
2.Well Construction Permit#: �J w �S g �7 �� A FROM TO I DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(Ii.e.UIC,County.State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in,
Geothermal(Heating/Cooling Supply) &Residential Water Supply(single) fL ft.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
hTi ation FROM TO MATE EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ® tt. G ft. n yl ea V l
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19..SANDlGRAS'ELPACK if applicable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test E)Stotmwater Drainage
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additimW sheets if necessary)
Geothermal (Heating/Cooling Return Other(explain under 421 Remarks FROM TO DESCRYMON color,hardness,soil/rack type,grain size,eta
0 ft. 2 ft. ?;,Os-,,71
4.Date Well(s)Completed: 7'234 of j well um fL -7 fL j4 rl
5a.Well Location-
rr pp fL Qi9 fL ,S a and s e
Sca* 6o trlvQ 0 ft. 810 it. crnr
Facility/Owner Name Fa ility ID#(ifapplicable) ft ft
S101 rulew IJ i�it7>erg�t a76a� ft.
Physical Address,City,and Zip ft. ft.
[70 1 1 J 1 a 0 ? 2t:Ri i1iAR1CS
County Parcel Identification No.(PIN) TWO
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification ��10� �g�lpn
N w
ONIR
6.Is(are)the well(s)dpermanent or Temporary Signature of Certified Well Contractor Date
By signing this farm,I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or dNo Kith 15A NCAC 02C.0100 or 15A NCAC 02C.0100 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 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:_ I— / ([ It SUBMTTTAL INSTRUCTIONS
9.Total well depth below land surface: l 8 V (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi,Jferent(example-3@200'and 1@100� construction to the following:
10.Static water level below top of casing: `0 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
/s above, also submit one copy of this form within 30 days of completion of well
12.Well construction method:_�f ��u construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) tP
Division of Water Resources,jUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
p,,�t i
13a.Yield(gpm) Method of test: �it W 24c.For Water Supply&Infection Wells: In addition to sending the form to
the addresses) 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.
I
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Res.- s Revised 2-22-2016