GW1-2021-06558_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well ContractorInformation:
Ua r `` 3 ✓ ,,top `J 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft. r S 0.n
s
NC Well Contractor Certification Number tpC ', .OUTER CASING(for multi-cased wells)OR LINER(if a livable)
y ^`���`0(���gG\ OM T� DIAMETER THICKNESS MATERIAL
4-
Company \ `)Y 6 , `\� -�tR'1,Ft lr ft. in. VL.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 3�c)0$�' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,Cou;iry,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in•
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public �ft. ft. ^� in. ,t
❑Geothermal(Heating/Cooling Supply) VIdential Water Supply(single) ft. ft. oS in.
❑Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
❑Uri ation ❑Wei Is> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
❑Monitoring ❑Recovery
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 ❑Stormwater Drainage JIRO ft. Sq ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: '- Well ID# \ ft. S ft. -
Sa.Well Location:
atiion:�/�, ft. 2` ft. b\acv_
�lJ� 1 U lX/�r�r 1 fL -3'5 fL
Facility/Ow er Name Facility ID#(if applicable) ft. 5.1
! ft. r`
tn ?bl \ �
Physical Address.City,and Zip
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well(ffield,one lat/long is sufficient) ( 22.Certification:
0 N �A }�� ((�`-1� c
6.Is(are)the well(s):Idermanent or ❑Temporary Signature of Certif Well Contractor Date
,,��([�� h�signing this form,1 hereby certifi'that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 0 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
1f this is a repair,fill out known well construction information a d explain the nature of the 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 construction info
construction,only I GW-I 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 surface: ✓ A) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
If Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/f water level is above casing,use"+"
24b.For Injection Wells: Copy to DWR, Underground Injection Control(FUC)
11.Borehole diameter: S (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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) OCR Method of test: L �mp
13b.Disinfection type: -lVA Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018