GW1-2021-05445_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES.
Well Contractor Name FROM TO DESCRIPTION
ft.f
c�'�G.S`-�.�' t. �! Sift' a O m
ft
NC Well
Contractor Certification"N'umberr 15.OUTER CASING for multi cased wells OR LINER a ll-No
Up/ rO11�' W L C FROM ft TO tt D in. TtffCKNFSS MATERLIL
ComXyName
/ G n 16.INNER CASING OR TUBING faeothermal closed400 .
2.Well Construction Permit#: V w- TKO �Ge7s o FROM TO DIAMETER THUCKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft IL m,
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. fL In.
❑Geothermal(Heating/Cooling Supply) elfesidential Water Supply(single) fL ft. in
❑Industrial/Commercial ❑Residential Water Supply(sham) 18.GROUT
❑lrri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (� tt a(3 ft ' la
❑Monitoring ❑Recovery ft. ft
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVELPACK ifapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT MET110D
❑Aquifer Test ❑Stormwater Drainage ft. ft-
❑Experimental Technology ❑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,hardy soil/rock eta
bit. ft. o Sa"'t
4.Date Well(s)Completed:J^ d� I Well ID# 6 fL C 6♦
5a.Well Location: iD6N. s-6 M S d-I
&M e% cL1 `fo h p ft- ft. 14 fL .® "
Facility/Owner Name 1 Facility ID#(if applicable) ft. ft.�L�OtO ylloh.S C-&Q.f"\ fL rt
Physical Address,City,and Zip ft R' wi✓S,ino llli
21.REMARKS... _ I live.,
County Parcel Identification No.(PIN) e- Q a e„ r r r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(long is sufficient) 22.Certification:
N W
w- �'-
6.Is(are)the well(s): GHKe'rmanent or ❑Temporary Signature of Certified well Con Actor 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 eidsting well: ❑Yes or IlerrO 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 attacb additional pages if necessary.
hued' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: A ! (ft-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2Qa 1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: a (ft.)
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
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: 4 Af �/ 24c.For Water Supply and Open-Loo 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
Permti Program,1611 MSC,Raleigh,NC 27699-16 1 1
13a.Yield(gpm) � Method of test:�D!�
13b.Disinfection type: Amount: €
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018