GW1-2021-04657_Well Construction - GW1_20210514

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: - —
1.Well Contractor Information: P,9�
(�/ `' •• 14.WATER ZONES
Well Contractor Name s 9 FROM TO I DESCRIMON
b fQ
NC Well Contractor aidTnNumbcr• , � CI ,3ilvt11R 15.OUTER CASING for multi-caved"wells OR LINER a livable
FROM TO DIAMETER THICKNESS MATERIAL
lr A t ,j1 i'✓ ft. ft. , in.
Company Name I V C',
u fi a 1 16.INNER CASING OR TUBING eothermal t'losed-loo
2.Well Construction Permit#G W 6 t y ' O I FROM TO DLIMETER I TMCKNESS I MATERIA
List all applicable well C011SWuction pelrnik(i.e.U1G Counp•,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft• ft. i°•
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Hcating/Cooling Supply) NRcsidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared)
18.GROUT
bri ation FROM I TO MA EMPLACEMENT MMOD&AMOUNT
Non-Water Supply Well: Q R• 19 R• porK,(LAJ r4f v,l
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
Aquifer Storage and RecoverySalinity Barrier 19.SAND/GRAVEL PACK 1f aticableFROM TO F MATERIAL F EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. ft
Geothenmal(Closed Loop) OTracer 20.DRILLING LOG:attach additional sheets if necessa
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) I
FROM TO DESCRIMON color,hardness,soiltmek type,grain size,etc.)
4.Date Well(s)Completed: 5 Well ID#
C Qt�tt T w_..K��• ( ft• ft'
t 14V N Ill n. O ft. ✓
flaciiiN/Owner Name hv*j
Facility ID#(if ari»ticablel p R t(tt G cO(, C04
Physical Address.City,and Zip
I f IC 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifi tion:
N W _�I)A2JAj
6.Is(are)the well(s)dpermanent or Temporary Signature of Certifie Contra for Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or dNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
�rehr,;� .or ;, pit­e t-„..,.m ,ott.��o+.,.�n ;fir.. �; . ., t m„t ;,�l o„ n,.o�t rye copy of this record has been provided to the well owner.
repair under#21 remarks section or on lbe back of this)onn.
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
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drilled' I SUBMITTAL INSTRUCTIONS
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10.Static water level below top of casing: v (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 Injection Wells: In addition to sending the form to the address in 24a
A 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 push,etc.)
r-R.n Division of Water Resources,Underground Injection Control Program,
III ._.
13a.Yield(gpm) Method of test: 24c.For Water Supply'
&Injection 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: 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