GW1-2021-03636_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ( '
14.WATER ZONES
Well Contractor Name FROgM TO DESCRIPTION
ON
6� /!00' f �ft. ft
NC Well Contractor/Certification Numbe///r���1 I .OUTER CASING for multi cased wells OR LINER d a licable
&A� I FROM TO I TIC S MATERIAL
Ib 1 C, ft. .� ft. � i in. sL y J
Company Name 64
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc) ft. ft. in,
3.Well Use(check well use): ft. fL in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ID! icipal/Public /ft. ft. in. J C
Geothermal(Heating/Cooling Supply) JB Residential Water Supply(single) ! ft. ft. in•°
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
1tri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft C tt O
v/'
(—Monitoring DRecovery ft. fL
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK If applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MgERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage CPQ ft. ft. 2�16-
..
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) 0TraceT 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ! Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnp&soiltrock type,grain size etc.
4.Date Well(s)Completed: V 1 I Well ID# ft. ft. Lr lit
5a ft.
.We,U oc �f
W
Facility/Owner Name Facility ID#(if applicable) Z ft. 7 (D ft A s e
�3"1 ��OUQJ✓ I�(�i�1. NG ft. �- ft. s�� ����. ti
Physical Address,
//City,
,aand ZIP/ ft. ft.
��Q.1/V 21.REMARKS
County JJJJ Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certifieahon•
N W 01 Ld f 1
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified Well Contractor Da
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: OYes or �No with 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 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.
filled: / SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (D-) 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,
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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: /Lt ti 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 Supply&Injection 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: cs;.,o Amount: 3 completion of well construction to the county health department of the county
where constructed.