GW1-2021-06042_Well Construction - GW1_20210901

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WELL CONSTRUCTION RECORD 1) For internal Use Only:
1:Well Contractor Information: a
{ 1✓* f; 14.WATER ZONES I
a,` a
Well Contractor Name FROM TO DESCRIPTION��, ,,..� y [t. 0 ft. �
- - '-�3 A
NC Well Contractor Certification Number C '�jill�
J ;;;"0 15.OUTER CASING for multkased wells OR LINER a llcable
0 f��� 1 ' I,;O� FROM TO DIAMETER THICKNESS MATERIAL
ft. fL
16.INNER CASING OR 7 UBING(geothermal dowd-loo
2.Well Construction Permit#: 7(p 17 FROM TO D ETER THICKNESS MATERIAL
List all applicable well construction pennfts(i.e.UIC,County,State,Variance,etc.) ft• ® 11L
V U
3.Well Use(check well use): ft ft' in.
SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. a, hL
Geothermal(Heating/Cooling Supply) ffiResidential Water Supply(single) ft, fL to
Industrial/Commercial Residential Water Supply(shared) is.GROUT
Irrigation FROM I TO MATERIAL I EMPLACEMENT All"OD&AMOUNT
Non-Water Supply Well: ft. I o ft. o O (Ah rQy`
Monitoring J3Rcovery ft. ft. 95 j.D
Injection Well:
ft, ft. �Q
Aquifer Recharge Groundwater Remediation
45
19.SAND/GRAVEL PACK If.a ilca e
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. IL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal eatin Coolie Return Other(explain under#21 Remarks FROM TO DESCRIPTION color hardness,soluroch type,own dZ16 etc.
& ft. a r 0 G
4.Date Well(s)Completed: 1-3-a I Well ID# ft. ft.
Sa.Well Location: ft• ft•
Facility/Owner Name Facility Mi(ifapplicable) % tL
I V I l fb c a'�5 ft. ft
Physical Address,City,and Zip ft ft'
e, 21.REKARKS
Cam Parcel Identification No.(PIN) Qc f go '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Q �'
(ifwell field,one W/long is sufficient) 22.CrgA
N W A 3
6.Is(are)the well(s)dPermanent or Temporary S' of Certified Welt Conttac Date
By signing this fonm I hereby certify that the welts as(were)constructed in accordance
7.Is this a repair to an existing well: S(Yes or []No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Srandards and that a
If this is a repair,fill out known well construction information and explain the nature ofthe 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 I OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
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drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �q - -(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well.:,.-
For multiple wells list all depths ifd8erent(example-3@200'//a��nd 1@1001 construction to the following:
10.Static water level below top of casing: �V (ft.) Division of Water Resourcees,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:i (In.) 24b.For Inlection 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: tP 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: i t 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Suooly&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: Amount: T completion of well construction to the'county health department of the county
where constructed.
Fort OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016