GW1-2021-04214_Well Construction - GW1_20210415

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
-rQ 50V\ �®V It 14.WATER ZONES
Well Contractor Name ���� FROM
ft• TOLO it.
DESCRIPTION
1 ft. ft.
NC Well Contractor Certificati n Number 15.OUTER CASING for multi-casedmelis OR LINER if u lieable
YG d I r'.� 2021
4 \.I I , �` - FROM TO DIAMETER THICKNESS MATERIAL
/ W N"ifr^ ���^,,(((JJ t, ;! �Z'. U',.t ft ft. in IV
Company Name �ti:.,i I': %� ,n f -" it A
t I���j 01 q _t't7 �. 1 -fio ! 16.INNER CASING OR.TUB G.' eothermal elosedaoo
2.Well Construction Permit#: l%I w ✓ �! "C FROM I TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UiC,County,State,Variance,etc) ft. fL In.
3.Well Use(check well use): ft• ft. in.
Water Supply Well: 17.SCREEN
PROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. g• rn:
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 2,p ft, a �i
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19..SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test J3Stormwater Drainage n IL
Experimental Technology Subsidence Control it. ft.
Geothermal(Closed hoop) Tracer 20.DRILLING LOG'attach`additionel sheets if necessa
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIMON color,hardness sail/rock typc in size,etc
ft. % d l
4.Date Well(s)Completed: _3 Well ID# 2 ft. ft. Q
5a..Well
elllLocation- g{ O
V!11( yl� rn GI v l Lk ft. fL
Faciilliity/O/wrieer Name ,-` Facility ID#
m ifJapyplicable) R• ft.
i+.f�(/�6 rU` ` � ft. ft.
Physical
Address,City,and Zip
V F -Ili
R' R'
V f1{`r le— j�l 11 �1 !-Il i 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 22.Certification:
N W PDL J-211 3. 3)- J
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Contractor 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:-[]Yes or dNo with 15A NCAC 02C.0100 or 1 SA 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#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
constructior only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: y� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: "8 00 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdiffereni(example-3Q200'and 2Q100� construction to the following:
10.Static water level below top of casing: Z (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For In Wells: In addition to sending the form to the address in 24a
'f"yU,N/ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: f i construction to the following:
(Le.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) ` 5 Method of test: d"_ 24c.For Water Supply&Iniecdon Wells: In addition to sending the form to
+ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: y Amount: t completion of well construction to the county health department of the county
where constructed,
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources( Revised 2-22-2016