GW1-2021-05978_Well Construction - GW1_20211025

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
/7 i4 K/- f/`✓LM > 14.WATER ZONES
F
Well Contrac r Name FROM TO DESCRIPTION
fL 6/7 ft•
3r?6A ft. fL
NC WellContractor Certification Number 15.OUTER CASING for multi-cased'wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
fL ft in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: ky-z -G /`� FROM I TO I DIAMETER L THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) fL fL im
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M it.unicipal/Public fL i in.
❑Geothermal(Heating/Cooling Supply) ENG'sidential Water Supply(single) ft• ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT,
❑hri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft- ?S fL CC�-it
❑Monitoring. ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK d a Ilcable
❑Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. fL
❑Experimental Technology OSubsidence 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,soWrock bqw,grain sire,eta
p 0 ft (� ft.
4.Date Well(s)Completed: Zg' Z Well ID# fL CL
5a.Well Location: ft. ft.
ft. fL 2
On/I a 41n q
Facility/Owner Name Facility iD#(ifapplicable) ft. fL
eXIIIA t�->OX-141 -272c 3 ft ft. toy, 1 003\
Physical Address,City,and Zip ft. ft. ,(�
6' 77r J 7 21.REMARKS n /
County Parcel identification No.(PIN) a �Xt s>(' w�/I X. a o l 7v(o t/O/d 11 (" 0)
r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 4:t�A N 11^ -', C4, 0^ -Zee
(if well field,one lat/long is sufficient) r 22.Certi ation: d 7 ol u Q 76'
360 a8, Y&I N 79°tz. 6 9i W _
m �k- 6r zs'-zj _
6.Is(are)the well(s): MPeranent or ❑Temporary Sienature o ertified We11 C n for Date
_�� By signing this form,thereby certifv that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ia'Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/£this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this fonn. 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: 6 gd 00 Submit this GW-1 within 30 days of well completion r the follow'
For multiple wells list all depths,if different(example-3®200'and 2@1001 y �'
10.Static water level below top of casing: t�S (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use-+" information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ✓ 24c.For Water Sunniv 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(gem) Method of test t; O Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Nr _ Amount: 54707.
07
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 64-2018