GW1-2021-05451_Well Construction - GW1_20210527

L Well Contractor Information:V I I
u'S 0 6 a` 14.WATER ZONES k
Well Contractor NameFROM TO DESCRIPTION
o
ft. 1 a ft' ;.C F
NC Well Contractor Certification Number 15.OUTER CASING for multl-cas ells OR LINER Of a licable
FROM I TO DIAMETER I THICKNESS MATERIAL
• ft. 1 ft. ; in. I
y
Company Name
I _ q 16.INNER CASING OR TUBING eothermr<t closed-loo
2.Well Construction Permit#: �7 W 1 3 O 7 FROM TO DAMETER THICKNESS MATERIAL.
List all applicable well construction permits ri.e.UM,County,State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): tt. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SUM THICKNESS MATERIAL
Agricultural unicipaUPublic ft. It. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) 18 GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. Z l7 It. 'aI ua (by
Monitoring Recovery ft. ft. Lt!Nt Lh 1
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK f a`llcable`
Aquifer Storage and Recovery [3Salinity Barrier FROM I TO MATERIAL. I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attaeh.additlonal:sheets if ueeess
Geothermal Heatin Coolin Retum Other lain under#21 Remarks FROM TO DESCRIPTION color,hardness sof eek type,grain size,etc.
tt. a. tt. b O t
4.Date Well(s)Completed: Well ID# a
5a.Well Location: �5 fl' o R' G►N 11 r 6 L
ft. ft.
lr 4r ldh
Facility/Ownef Name Fa ility ID ,
(if applicable) ft. ft.
��a) TAB►<soln kf<g 'T R� �
Physical Address,City,and Zip
Il t 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.Certification:
6.Is(are)the well(s)dPermanent or OTemporary Signature Certified Well Contractor Date
By signh this form,I hereby certify that the ivell(s)was(were)constructed in accordance
7.-Is this a repair toan existing well: - E)Yes or QNo Wth 15,4 NCAC 02C.0100 or 15A NCAC'01C.0200 Well Constriction 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: 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: U (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d(fferent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: O (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
f-
11.Borehole diameter: (in.) 24b.For Iniecdon wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: C A construction to the following: t
(i.e.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
^� i
13a.Yield(gpm) d"S Method of test: 'aW 24c.For Water Supply&Iniection.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:---6 Amount: Z k 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 f Revised 2-22.2016