GW1-2021-06573_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
C D C Y-s le 60,Yx
ft. ft.
NC Well Contractor Certif anon Number 15.OUTER CASING(for multi-cased wells)OR LINER if a 0cable)
FROM TO DIAMETER THICKNESS I MATERIAL
ft. 09 It. i a in. � G
Company Name 1
r2,` 2� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: W G1 J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,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.
a in-
a scnqv vc.,
❑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. 010 Ft.
❑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 Drainageft.
❑Experimental Technology El Subsidence Control ft. Ft.
❑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 t e, rain size,etc.)
� ft. 16
O 1
4.Date Well(s)Completed: �X of O �1Well ID# ft. ft. C(Q
5a.Well Location: ( ft. et. C U
�)cir(\jg1
Facility/Owner Name ]� Facility
IIID,#(if applicable) ft. It.
l ,� C (AVSQ A
Physical Address,City,and Zip ft. ft.
!S�Myjnn . o 00 sq a -136 21.REMARKS
County Parcel IdentificationNo.(PIN) OLI
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: p ,. 11
(if well field,one lat/long is sufficient) 22.Certification: InSofll"�©v� i O
_ R 5$ci o
JCt41 N JB t.53��I W `
6.Is(are)the well(s): ermanent or ❑Temporary Signature of Ce red Well Cont for Date
, Al,signing this form,l herebY certifi that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or dri0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a coP),
If this is a repair,fill out known well construction information and 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 ifnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dii ferent(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
1f water level is above casing,use"+"
' n 24b.For Injection Wells: Copy to DWR, Underground Injection Control(fUC)
11.Borehole diameter: W (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: l Y-lJ�C��'� 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) 13 Method of test:
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
171lQ ram_
^
13b.Disinfection type:� \ VA- Amount: N
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018