GW1-2021-06566_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
1 I -S 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
SLQ�-
_ ft. cal ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a livable)
\ ^`•'`Vk-�I T J+ _�. /�`` 1 •1`1; FROM TO DIAMETER THICKNESS MATERIAL
Company Name
- t 16.INNER CASING OR TUBING eotherma]closed-loop)
2.Well Construction Permit#: `-C 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. ft. r] in.
❑Geothermal(Heating/Cooling Supply) /I�sidential Water Supply(single) ft. ft. v� in. f
❑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: ft. cR Oft.
❑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 ® ft. ft. #�
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) R. ft.
sow
4.Date Well(s)Completed:�'1C7 -� Well ID# ft. ft. Iced Sh u \
5a.Well Location: ft. ! ft. .L' e G 1 a
N`'U�r� �yn� rt. 3 ft. u a C C,
�
Facility/Owner Name Facility ID#(ifapplicable) ol 2FL ft.
c �y� � ✓ Yl �n
l� j� �Z'Ylh� ��� 1 t tll, �� ft. ft. .
Q
Physical Address,City,and Zip
M,'q1� ©� 21.REMARKS
SsanXLQ� UU
County Parcel Identification No.(PAIN) jRg 11
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
In#or�.ation r o ..i'n
(if`well field,one Iattlong is sufficient) p �` 22.Certification:
we
J5 t I � 3 10ILP n N 1 . 7 W c t
Gt-fiLr�1 L✓ �/� '
6.Is(are)the well(s): 'Permanent or ❑Temporary Signature ofCertified II Contractor T'- 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 ANO 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 dnnd 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-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: or (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 (DR),
If Static water level below top of casing: (ft.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
W
lj water level is above casing,use"+"
24b.For Iniection Wells: Copy to DWR, Underground Injection Control (IUC)
11.Borehole diameter. (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: \1��0.14 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
13a.Yield(gpm) Method of test: V 1
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: I Amount: L-
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018