GW1-2021-05934_Well Construction - GW1_20211115

1.1.11 Its Vllir
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
1�l�1� \ WL� 14.WATER ZONES i
Well Contractor Name FROM TO DESCRIPTION
ft, ft. I I
f, ft.
NC
Well Contractor Certifications Number 15.OUTER CASING for:malti-cased wells OR LINER If ticable
�Jt \ 'M k \N t�tk�Um� CO FROM TO DIAMETER THICKNESS TERIAL
ft. ft.Company Name
,,2 I&INNER CASING OR TUBING eotherroaI closed-lootil
2.Well Construction Permit#: VW 'O�V Cl JO'�V{. FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits f.e,U1C,Couno%State, Varidmile,etc.) ft. ft, in.
3.Well Use(check well use): tt. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public tt, ft, in.
Geothermal(Heating/Cooling Supply) MAidential.Water Supply(single) tt. ft. in.
Industrial/Commercial EfResidential Water Supply(shared) 1&GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
Monitoring 'Recovery
Injection Well:
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK_-(if a 1[cabie
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage ft. fL
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILL ING.LOG fattachliddiflonalsheets if.necessarV
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DFSCRIPTION Color hardness,soil/rock Ins etc
ft. ft. CM
:JC4.Date Well(s)Completed: Z Wen ID# 20 ft. rt.
Sa.Well Loca'on:
ft. ft.
VtW�M a . V
Facility/Owner Name Facility ID#(if applicable) ft. ft.
___Sn6 ft.
Physical Address,City,and Zip ft.
IN1 �/ 2L REMARKS
County r Parcel Identification No.(PIN) INFORMATION PROCESSING U!
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one IaUlong is sufficient) 22.Cel''6cation:
N w rI
6.Is(are)the well(s) Permanent or OTempori�K,
r Signor of Certified ell Contractor Date G
By signing this form,I hereby cer6fv that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 11Yes or with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
Ifthis is a repair,'ll out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#11 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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
9,Total well depth below land surfacer (fW 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths Ijdi�/w ens(example-3(w2UD'and (ryl UU) construction to the following:
10.Static water level below top of casing: 10 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above caring,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: �i(in.) 24b.For Inieetion Wells: In addition to sending the form to the address in 24a
above, also submit one copy of thisl form within 30 days of completion of well
12.Well construction method: MT((��['1 construction to the following:
(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 276994636
13a.Yield(gpm) 7 Method of test: V 24c.For Water Supply&Inieetion Wells: In addition to sending the form to
the address(es) above, also submit lone 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