GW1-2021-05556_Well Construction - GW1_20211013

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor InformationP �a�gtlt,.p
o F C.b I t F 14.WATER ZONES
Well Contractor Name FROM TO J DESCRD'TION
VIN ft, 2 G, '�"
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NC Well Contractor Certification Number \ �CQGeO. 15.OUTER CASING for multi.cased wells OR LINER If o licable
r a i7 n I. IC t �� �+ FROM TO D THICKNESS MATERIAL
V W � 3 •
,`'' ft. ft. In. k-e't V
Company Name
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1 J 16.1NNER CASING OR TUBING' eothermat closed-loo D
2.Well Construction Permit#: (��( J Q '�o z l FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft.
Water Supply Well: 17.SCREEN
FROM TO I DIAMETER L SLOT SIZE I THICKNESS I MATERIAL
Agricultural unrcrpal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) f Residential Water Supply(single) ft. ft. I in.
Industrial/Commercial Residential Water Supply(shared) 16.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. v ft. rl i l-1
Monitoring Recovery ft. ft
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stonnwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach addidonalsh'eets if necess
Geothermal(Heating/Cooling Coolin Return Other ex lain under#21 Remarks FROM TO DESCRIPTION color,hardness soilirock in etc.
Non-Water
Q ^l ft. ft. G
4.Date Well(s)Completed: v— +°c/ Well ID# ft. .2/jt.
Sa.Well Location: -
/� f„�� ft. ft.
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Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
3 03 L !n krqj Jr. (ap-1 2 7511 ft' ff
Physical Address,City,and Zip
[A >a)c Q /5 a 8 5 q l 3 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Ce fieatIon: z 1
N W � Z3Z1
6.Is(are)the well(s) Permanent or OTemporary Signar of Ccrtified Wen lontractor 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: DYes or QNo with ISA 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 thus 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 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 a d (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(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,
Ifuater 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
1PbL /7 14r above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: /n 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 m Injection Wells: In addition to sending the form to
1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: I t completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016