GW1-2021-05450_Well Construction - GW1_20210527

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JAto _14:-WATERZONES
FROM TO DESCRIPTION
Well Contractor Name
& ft
NC Well Contractor Certification Number ,15.'OUTER..CASING formUl nsed:welus' IMEittCifbily bltl',,-'"t,
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r/s�r I` (AC t t CC/ FROM To D THICKNESS MATIIUAL
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Company N e /�' [" /�^0� �f 16..INNER CASING:OR.TUBING, theroi it closid-too
2.Well Construction Permit#: 6+W 1 0�7 b y `' 2,0 y' FROM TO DL4ML =I TIECKN Ess I MATERML
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) fL ft. m
3.Well Use(check well use): ft ft.
fr' rO
Water Supply Well: lY.SCREEN,. "
FROM TO .DIAMEfER..�:SLOT SIZE THICKNESS I MATFdUAL '`..
Agricultural [3Municipal/Public 0 n, ft, in.
Geothermal(Heating/Cooling Supply) esidenhal Water Supply(single) fL ft. ;n i
Industrial/Commercial EIResidential Water Supply(shared)
18:GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (� ft. Ae) f 6 e at
Monitoring Recovery fL ft,
Injection Well:
Aquifer Recharge DGroundwater Remediation 19:SAND/GRAVEL PACK rf a 1elieab Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage fL fL
Experimental Technology EJ Subsidence Control ft. fL
Geothermal(Closed Loop) Tracer 20,DRILLING LOG'attach additional sheets if.Mcess
Geothermal Heatin Cooling Retum Other(explain under#21 Remarks2j
FROM TO DESaUPTIOx color,bardnesN soturocg qrpc,pain sae,etc
3 ft. � s�rr
4.Date Well(s)Completed: Well ED# 3
ft. 0 & C N
5%Well Location: 20fL O �" I V
/�y Awl G s--fJ ��rs'e ft. ft.
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Fac�il/ity/(TwnerNaym�e Facility M#(ifapplicable) fw ft.
Tr1pn.s GHQ ft. ft .,.,,a;en prasass'tr�g Ul;i1
Physical Address,City,and Zip f, fL ®i!b'',5,J=ucvon
k-C 21 REMARKS
County 'f Parcel Identification No.(PIN) - I 'e4%` J&tree Shot L
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one lat/long is sufficient) 22.Certification:
N W J r
6.Is(are)the wells) Permanent or 13Temporary Signature of ertified ell Contra r 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: []Yes or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 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 if necessary.
drilled:
/ SUBMITTAL INSTRUCTIONS
F Total well depth below laud surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@20^0'and 1@/00') construction to the following:
10.Static water level below top of casing: d-� (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276"-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
bi>%tP/ above,also submit one copy of this within 30 days of completion of well
12.Well construction method: s
(i.e.auger,rotary,cable,direct push,etc.)
construction to the following: j
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276"-1636
13a.Yield(gpm) Method of test:_ 24c.For Water SunvIv&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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016