GW1-2021-06565_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
LOXN `!V i W \Oye _J✓ 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. Us� ft. Y
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if applicable)
FROM TO I DIAMETER THICKNESS MATERIAL
l ` T + k ft. ft. in. SJ
AVL
Company Name �y �( 16.INNER CASING OR TUBING(geothermal closed•loo ) l'
2.Well Construction Permit#: W G a ClanCL.e(4 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 151-P. Ut. in• k` V L
❑Geothermal(Heating/Cooling Supply) LyOdential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑h-ri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ct. Oft. _ 5 S�
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑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
❑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,soiVrock type,grain size,etc.)
n(� D ft. ft. 4c)P5 0
4.Date Well(s)Completed: (�` 2 Well ID# t ft. ft. sat &A _1
5a.Well Location: ft. ft. 1_ a C:1
ft. ft. 1D ��
Facility/Owner Name Facility ID#(if applicable) 5 ft. ft. S
Q '�U 1 ft. ft.
Physical Address,
City,and Zip t ' ft. ft.
5Jo' I r V sl�2 21.REMARKS
County Parcel Identification No.(PIN) Utlii
s 660'0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,
onelat/long is sufficient) 22.Certification:
/ _n
l QU N �. i � i 13S W c r
otr ft W g,Gl.
6.Is(are)the well(s): 961,manent or ❑Temporary Signature ofCertifofi Well Contra or 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 ' 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 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 if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Cp (ft.)
For multiple wells list all depths if different(example-3q@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
1� (ft.) 24a. For All Wells: Original 'form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
' w 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter: fit/ (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) 1 10 Method of test:
13b.Disinfection type: ��(1 t Amount:
T
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018