GW1-2021-05329_Well Construction - GW1_20211013

S CONSTRUCTION RECORD(GH-1) For Internal Use Only:
1.Well Contrac r Information: /(,.
�/ V C e� 14.WATER ZONES
Well bontractorName FROM To. DESCRIPTION
tt f Gn f�, M �3 3�
NC Well k or�eertificatimr umber OCj 1 V ft 14 ft. �'o{* ! idwn add a.
YADIaN WELL COMPANY,INC. r ���� ce o� FRO LITER CASIl�iG four ni Dti-METERcased ellms)ORS S a liMAlTE�
Company Name
� '� � 16.INNER CASING OR TUBING(geothermal dosed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) f- ft ft t `, in.
^;I- SOI vc-
3.Well Use(check well use): ft' ft I in.
Water Supply Well: ]7.7SCREE,N j
PP y FR TO DIAMETER SLOT SIZE THICICNEss MATERIAL
❑Agricultural ❑Municipal/Public ft. in•
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT �
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT {
METHOD&AMOUNT 3
Non-Water Supply Well: 0 it. 8. ,n nW l &AipCpec-tred
❑Monitoring ❑Recovery (,t ft ft. fps&
Injection Well: % g, re-�
❑Aquifer Recharge ❑Groundwater Remediation `
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑salinity Barrier FROM TO MATERIAL. EMPIA CEMENT METHOD 75
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM To DFSCRzpTlox
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) color,hardness,sniuroek sae,CcL
c b S t_
4.Date Well(s)Completed: t�rJ V�� Well D##QQ - 5 14 J? e L
5a.Well Location: Phone # ql r-113433;tIli ff. 'S7 fL
�n i(I;� 16 AIIvJon -ea9(A& rl 0 -43.3-1T-33 ft' os fL
Facility/Owner Name'' Facility ID#(if applicable) t Q s ft' `6. ft ('
i GG
2.6? ('(ape., /f reek . NCW JAAd
Physical Address,City,and Zip � �� ft. fL
3 u i kr- 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
3S' S7 3133 N W1 Sao 691'l W 30-,•L
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signature of Certified well Contractor Date
By signing thisform,I hereby certify thatthe wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or �W'. 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided 10 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 4l 0 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths 1f different(example- and 2Q100)
got 24a. For All Wells: Original.form to Division of Water Resources (DWR),
f Static water level below top of casing: `l O o (ft.) formation Processing Unit,1617 MSC,Raleigh,NC 27699-1617 e
Ifwater level is above casing,use"+" V,
11.Borehole diameter: (in.) Bit Off: 51 ! o 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY (fO
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed dj5
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
a 13a.Yield(gpm) � Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
70%HTH [[ OZ DATE SITE VISITED:
13b.Disinfection type: Amount: :O
VISITED BY:
Form GW-1 r D_,4 f North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018