GW1-2021-05446_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 11
4,P; �r1CD0 S `14.WATER s- 3
FROM TO DESCREMON
Well Contractor Name
I a ?&�/ i` L it.
It, R
NC Well Contractor Certification Number 15.'O.UTER EASING'for multi cased wells ORI MW ifs' bk
,, n e f / T FROM TO DIAWIER THICKNESS MATERIAL
/
Co Name l)lJ l ( V ft (� ft lia
��y (.( 16-INNER CASING OR'1 UBING 'tliermdld Rah
2.Well Construction Permit#: /' D ` v ` FROM To DIAMETER TSICIGMs MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft ft. in.
3.Well Use(check well use): ft. & in.
W
l
ater Supply Well:: M
FROM TO DIAETER ?SLOT SIZE THICKNESS MATERIAL
Agricultural �Municipal/Public U ft. ft. in.
Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft. ft.
IndustriWCommercial []Residential Water Supply(shared)
18.GROUT-
Irrigation MATERIALs
FROM To MATERIAL EMPLACEMENT OD&AMOUNT
Non-Water Supply Well: ® ft. it.
Monitoring Recovery ft. ft.
Injection Well:
It. ft.
Aquifer Recharge nGroundwater Remediation
'•19.SAND/GRAVEL:PACK f 4 'li6bie
quifer Storage and Recovery 0I Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
quifer Test 13Stormwater Drainage ft. ft.
xperimental Technology Subsidence Control ft. ft.
eothermal(Closed Loop) ILLTracer 20.DRING LOG:attach additionaieothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,saureck sae,etc.
4.Date Well(s)Completed:J Well HW D ate fL C c4�
5a.Well Location: /J ft. r0 ft
Facility/Owner Name Facility ID#(if applicable) it. ft. 1A AT Y 2
/yo ? � n5 k �R ft. ft.
Physical Address,City,and Zip IL ft. IniGM131i' t
U 4''`e .2i REMARKS
J' , c
County Parcel Identification No.(PiN) , lP e
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well ontractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or r No with 15A NCAC 02C.0100 or ISA NCAC 02C.02o0 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy 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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: _ Y (fw) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
ifwater level is above casing,use"+r" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: l! (in.)
24b.For Iniection Wells: In addition:to sending the form to the address in 24a
0���,� above,also submit one copy of this jfonm within 30 days of completion of well
�
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) s Method of test: ow/ 24c.For Water SunDly&Injection Wells: In addition to sending the form to
/ 1 the address(es) above, also submit!one copy of this form within 30 days of
'f
13b.Disinfection type: Amount: 1A completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016