GW1-2021-06572_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
``'\l-W -:�N 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. "]"ftt
ft.
NC Well Contractor Certification Number (� 15.OUTER CASING(for multi-cased wells)OR LINER if a licable)
�x t l Vl �A FROM TO DIAMETER THICKNESS MATERIAL
1 r \ t/� +- ft. I 3t. I a in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: �� V y 13 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 J© 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. nt 3 ��b
❑Monitoring ❑Recovery ft. o) ft.
Injection Well: Y-
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 ❑Stotmwater Drainage r.
❑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,soil/rock type,grain size,etc.)
0 I ft. .�� 5o j
4.Date Well(s)Completed: �� Well ID# T ft. I ft. U-
5a.Well Location: I
ft. 1 ft. A G a
�V\1X== �bQ e=f Irl ft. 3 O ft. Yt t-Mg 1C i la
Facility/Owner Name Facility ID#(if applicable) c> ft- J? ft. u PLd
1\Z Casf!ey �� Dunn ryC 2-F_33� ft. ft.
Physical Address,Ci y,and Zip ft. ft.
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: n P[QCeSSIftC�Unit
(if well field,`onnee{Iat/long is sufficient) f�\ 22.Certification: DWR ecil
3l)1 1 l 1 N t 5 1� W w % 3 a
6.Is(are)the well(s):*ermanent or ❑Temporary Signature ofCerafied Well Contra or Date
,,,,,,,�[[[[-� By signing this form,I herebt�certifv that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or *0 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 an 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: 34 (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@I00')
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"+- n
11.Borehole diameter: `i (in,) 24b.For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rym Ze�avuk 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,a .) 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) V Method of test: Ui'Yl 6
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018