GW1-2021-05534_Well Construction - GW1_20211013

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
k.9 C6 �w` 14.WATER ZONES
Well Contractor am FROM TO DESCRIPTION
ri�
0�� s�n9 v & I A
NC Well Contractor Cartilication Number 15.OUTER CASING' mnm;cased welts OR LINER Ita neabll6
fr� FROM TO DIAhn3TER THI�C/jIileV6S3/� MATERIAL
�� .���� �L nt �1' EL ft. 6 in- �//G��i�
Company Name
' i16,INNER I Pic
CASIN OR TUBING eothermsl closed-loop)
2,WeU Construedon Permit#: FROM To DIAMGrFEit I TIRCKNESS MATERIAL
List all applicable weli construction permits(i e.UIC,County,State,Variance,etc.) ft. ft. m.
3.Weil Use(check wen use): ft, ft in.
Water Supply Well: 17.SCREEN
FROM TO I DIAMETER I SLOTSUE I THICKNESS I MATERIAL
Agricultural E)Municipal/Public 0 EL ft.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single)
ft. R. in.
Industrial/Commercial Residential Water Supply(shared) I&GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Welt: 10 ft. fL M
Monitoring _. Recovery ft. ft. f
lGeothermal
jection Well:
Aquifer Recharge [[Groundwater Remediation f19 SAND/GRAVBL PACE ncableAquifer Storage and Recovery Salinity Barrier FROM TO MATBlUAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft• R•
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if n(Heating/CoolingReturn) Other lain under#21 Remarks FROM To D1?scltlrrloN rotor nardn soilhvck Sze etc
IL
ft, 1
4.Date Well(s)Completed: WeU w A80ft. ft.
Sa.WeU Location: ft' 1
/I//ic- M ft.
Facility/Owner Nafne Facility ID#(if applicable) ft. ft.
ft. ft.
Physical Address,City,and Zip ft. ft
TQ ler sm 21.REMARKS._
County Parcel Identification No.(PIN)
5b.Latitude and longitude to degrees/minutes/seconds or decimal degrees:
(ifwell field,one laf/long is sufficient) rt 22.Certiftca"
c 2 `. W 7�O �Z�77Z:W 4I 23-Z/
6.Is(are)the well(s) ermanent or E3Temporary S' o . ed Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an erosting well: ®Yes or EW-000' with 15A NCAC 02C.0100 or ISA NCAC 02C.02W Well Construction Standards and that a
If this is a repair,fill out)mown well construction it{formation 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. 33.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: J:� CLr19Mrr AI-nv 333&11-rr[3N9
9.Total weU depth below land surface: 7!J (ft) 24a.For AU Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths!}different(example-3@200'ant(2@101 construction to the following:
10.Statue water level below top of casing: 2 (fL) Division of Water Resources,Information Processing Unit,
If water lever is above casing.use-+- 1617 Mail Service Center,Raleigh,NC 27699-1617
f
11.Borehole diameter.— & 1 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
.Well construction I1�dlod above,also submit one copy of this form within 30 days of completion of well
(L � �
(i.e.auger,rotary,cable,direct push,,etc.) construction to the following:
Division of Water Resources.Underomand Nection 0—t-1 P..oBeam,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service iCenter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test or Water Supply&Infection Wells: In addition to sending the form to
the a s(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 7W Amount: completion of well construction Ito the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-201 6