GW1-2021-05449_Well Construction - GW1_20210527

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
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Y1.Well Contractor Informatlo
61 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
rL
Z21 q .
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'wells OR LMR if a livable
r ¢ u PFROM
TO DIAMETER THICKNESS MATERIAL
l� C� 5b ft ; in.Compatry Name / Z R CASING OR TUBING eothermal closed-loo2.Well Construction Permit#: CW-O J113I r �O TO DIAMETER THICKNESSList all applicable well constructionpermits fl.e.UIC,County,State,Variance,etc.) . I ft. in.
3.Well Use(check well use): ft. I ft.
Water Supply Well: 17.SCREEN: FROM To DIAMETER SLOT BUZ THICKNESS MATERIAL
Agricultural unicipaUPublic ft. ft, in
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) in
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
nImgation FROM I TO MA EMPLACEMENT KETROD&AMOUNT
Non-Water Supply Well: O ft.
Monitoring Recovery ft. f6
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if a Ucable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METROD
Aquifer Test OStormwater Drainage ft. ft
Experimental Technology Subsidence Control ft, ft.
Geothermal(Closed Loop) OTrucer 20.DRQ I ING LOG tattacb.addidonal sheets ff necessa
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardn sell/rock type,grain sim,etc
ft' Z ft 6 SOI
4.Date Well(s)Completed: Well ID# I ft. .^,If 5`` ft. a
Sa.Well Location: 12 ft �b a ft
I GI YY\W,K &rG w n ft. ft.
Facility/Owner N Facility ID#(if applicable) ft. ft. ,
�0
ft. ft. q
Physical Address,City,and Zip ft' ft' MAY 2 1 r� 20
1^I A 11-Z 21.'REMARKS Processing blift
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Cerdfrcatfon• _
N w
ent Si ofCertifi Well Contractor Date
i.Is(are)the wells) 1'erma>, or []Temporary
By signing this form,I hereby certify that the 40(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or dNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 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#11 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 Ybu may use the back of this page to provide additional well site details or well
constructiolt only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
wed' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ��O 00 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths if dderent(example-3®200'and 2@100D construction to the following:
10.Static water level below top of casing: ZO (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Vb 1 �r above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct':pusb,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: b 24c.For Water Supply&Injection Wells: In addition to sending the form to
ry1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 1 completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016