GW1-2021-04278_Well Construction - GW1_20210901

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
u s � �C�lN1�lJ Q l r r a W m 14.WATER'ZONES;
T FROM TO DESCRHTION
Well Contractor Name Zia'* w 30
SE_ �t 2021
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NC Well Contractor Certification Number r' r r,�t 3 � )rl ;
3`� 15::OUTER CASING for multi-castd wells OR LINER'rta ticabk : .
�L1� FROM TO DLIMFTER THICKNFss MATERIAL r
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Comp y Name s
r 16.INNERCASING OR-TUBING "thermal dosedaoo
2.Well Construction Permit#: b 5-Cy 3 2 FROM TO DMMETER I THICIOMS f MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) R ft in.
3.Well Use(check well use): ft. ft.
Water Supply Well: 17.SCREEN ,
FROM TO DiAMEIEB SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public 0 ft. fa in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft in.
Industrial/Commercial Residential Water Supply(shared)
IS GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (� ft.
R c !�
_ Monitoring Recovery ft. ft
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19:-SAND/GRAVEL'PACK rta 'licable " "`°
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD s•
Aquifer Test CI Stormwater Drainage R R
Experimental Technology Subsidence Control & ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional.abi ets if necess
Geothermal Heating/Cooling Return Other(explain under#21 Remarks) FROM To DESCREMON color,hardness,soil/rock type,gmin she,etc.
CJ ft. Iz
4.Date Well(s)Completed: Z l Well ID# l� ft. Z R Gakz
5a.Well Location: ft ft
Ln m Xoyi e_r ft ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft
I55- EaIIP.n 0 l-n It.
Phys'cal Address,City,and Zip ft ft.
2L REMARKS
14 County Parcel Identification No.(PIN) 5
5b.Latitude and longitude in degrees/minates/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N w 3 2,
6.Is(are)the well(s)dpermanent or OTemporary Signature of Ce Well ontractor D to
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or [3(No with 15A NCAC 01C.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.
drilled. p�p� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2D.J (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(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 Infection Wells: In addition to sending the form to the address in 24a
.Well construction method: above,also submit one copy of this form within 30 days of completion of well
a.l Y
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) Method of test: 0 24c.For Water SunDly&Inieetio I 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: I completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department ofEnviromnental Quality-Division of Water Resources Revised 2-22-2016