GW1-2021-06505_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name L� FROM TO DESCRIPTION
p1QGes51 ft. �n ft.
11
NC Well Contractor Certification Number 3�,a� 810
c l �` �R J 15.OilTER CASING(for multi-cased wells)OR LINER(if a livable)
FROM TO DIAMETER THICKNESS MATERIAL
lam\ 1 l ' ft. 1 ft. Le
in. w
Company Name
D^ 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: I x J 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. ft. in.
Water Supply Well: 17.SCREENFROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Oft. ft. 6 1 o 10
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type,gmin size,etc.)
ft. ft.
4.Date Well(s)Completed: 2� Well ID# ft. G+ ft. ran a--re Cla
/ ft. 1 ft. a a^
Sa.Well Location:
(���(_`�p �� �(� (��''►'(' 1 l
,
C�)af��
L
Facility/Owner Name Facility ID#(if applicable) a, ft. 0, ft. YAVe
Mn1 �Zg 3lft. o ft. YGl S�tl la
Physical Address,City,and Zip r � ft. � f(ft.
I�0,� ► YC� 0599-(0 17 5//.n1p 21.REMARKS �J�� l•
County Parcel Identification No.(PIN) o �"� rU
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3i) t 3`+-7g N -7y , v-�Ild 151
W H-q'Z�
6.Is(are)the well(s): Armanent or ❑Temporary Signature ofC 'red Well Contriktor I Date
�.(�� By signing this form,I hereby certify that the we/l(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or t711V0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a coPy
If this is a repair,fill out known well construction information and e`�xplain the nature of the of this record has been provided to rite 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 surfacer (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@2000'and 2@I00')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 11 S (ft.)
If water level is above casing,use"`+"
If Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 1 (in,) 24b.For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 7610,v 4'W Q0 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
` Permit Program,1611 MSC,Raleigh,NC 27699-1611
-(
13a.Yield(gpm) ,� , Method of test: 1�1 r l:`l�
13b.Disinfection type: i A Amount: \ 1�
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018