GW1-2021-04656_Well Construction - GW1_20210514

1II 11.i NI'I;I 1.
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
u 5 B'AOOI f- ` 14,WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. p ft.
ft. Y ft.
NC Well Contractor Certification Number
y r 15.OUTER CASING.for muld-cased wells OR LINER if a licable
�Po�ti�. �Q�ri1 ,�i` 1V'YrII�J^� in_ FROM TO DIAMETER CtIICIOYFSS MATERIAL
VVV```''' 11111i ft. ft. In.
Company Name / 16.INNER CASING OR TUBING eothermal dosed-loop)
2.Well Construction Permit#: - O l - o a FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e. UIC,Cinoity,State, Variance,etc.) O ft. 160
On ft. 14
in. v G
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural unicipaMblic ft. ft. In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
711rrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft' 2 D ft O Qv1 A l
Monitoring Recovery it. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK Rapplicable)
Aquifer Storage and Recovery E)Salinity Barrier FROM TO MATERIAL FMPLACEMENT AtETROD
Aquifer Test OStormwater Drainage
ft. ft.
Experimental Technology E)Subsidence Control
Geothermal(Closed Loop) Tracer .20.DRILLING LOG attach addidentii sheets if necessary)
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,sail/rack in d etc.
P ft. 910re.
• I-
4.Date Well(s)Completed: S - Well ED# I 16o ft I I t o ft 1 g ran i�f_ f'DGie
52.w_n
ba 1,1NA Dh ' ft. ft.
rr V 4 hS�r�_i1 H
Facility/Owner Name pp Facility ID#(if applicable) ft. ft.
a 1 o 1 b 1 d B L,N1 1, (C� ft. ft.
Physical Address,City,and Zip
ft. ft.
21.REEMARttS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Ce�fiealion:
N W /
6.Is(are)the well(s)dermanent or Temporary Signature ofCcrtified Well CContractor L Date
By signing this form,I hereby certify that the wall(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 6(Yes or [3No with 1SA NCAC 01C.0100 or ISA NCAC 01C.0200 Well Construction Standards and that a
Iffbir it ropes:.rt(�„ 4-.m 1-11­rwlrnnn:nr..>Mi--d o,rr..;,,:tio-0-1�n>.o copy of this record has been provided to the well owner.
repair under#21 remarks section or on file back aJ tillylorin.
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
- - _ !:nnninlr•iirvl!iriwiis Vnu nrny nixu aii;ir.i!nririi4irv!ai nn`!r ii n!-crc�»ro_
drilled.-,p SUBMITTAL INSTRUCTIONS
U '1 nrm!nnl!f!^ttrF hrl neo!•eTA an M2rn• �, 1rf! - .- - .,
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cuusirucilun iu lhC Iuiiuwmg:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+" 11 1617 Mari Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
.II-- above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Sbi c construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
.[`.'!^+TTl♦TTT!nS!L!^T Rl lS-T2 T[.et�TT<s_ 1 ..: .. • _ _ _ _�
L
13a.Yield(gpm) Method of test: O 1,P W 24c.For Water Suably&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: Amount: 112 16. completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016