GW1-2021-06559_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
�Y 14.WATER ZONES
Well Contractor Nam FROM TO DESCRIPTION
ft. ft. r
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a Gcable)
•` "; I �11 \'t FROM TO DIAMETER THICKNESS MATERIAL
l t ft. ft. a in. 5/
Company Name W 11
^ 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: a":�o 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.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. t. �'in. O d �vt,
❑Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: et. ® et. n h b S 150 16 e ZLO
❑Monitoring ❑Recovery
Injection Well:
ft. et.
❑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 IQ
ft. �� ft. _sar,�
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soilAmck type, rain size,etc)
fl. ft. 0
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ;•rl ft. a
V�� aojk ft. aO�� ft. sit C� ,,,, 0
Facility/Owner Name Facility ID#(if applicable) el, I
ft. 31 ft. t7ln ep
o yC Car vY C S� NZ.n� I ft- 34, ft. h 14e 5btr `L gve
Physical Address,City,and Zip ft. ft. �QC+_.`O
Rdhes U I I - o I- 0402) 21.REMARKS
County Parcel Identification No.(PIN) §O` O
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) � �-7 22.Certification:
�p
3� I 05 Lf N 1 t 059 W
/it/lit�'li
6.Is(are)the well(s): *manent or ❑Temporary Signature of Ce ied Well Contr for Date
�� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 5A 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/f this is a repair,fill out known well construction information ah 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 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 surface: 3(,0 (ft.) 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),
10.Static water level below top of casing: (ft') Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter: (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Pm 0AMVI4 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) 'T 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
13a.Yield(gpm) '0 Permit Program, 1611 MSC,Raleigh,NC 27699-1611
Method of test: �m i r
13b.Disinfection type: Amount: i/
LA
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018