GW1-2021-07064_Well Construction - GW1_20211129

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ."
/^ i
snr\_( 3, scw) 14.:WATERZONES
FROM TO DESCRIPTION
Well Contractor Name
/�
o ft. GyS-fit. l a iJ
4 01 1A"7 t ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if Applicable)'
�Wn Sea co I I nc FROM TO DIAMETER THICKNESS MATERIAL
ft ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed400
2.Well Construction Permit#: &'I/,l .� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc) O fit W d ft /_• f in. I? SkAj
3.Well Use(check well use): ft 0 ft. tv m._
17.'SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural �Munl ' /Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fL ft. in.
Industrial/Commercial Residential Water Supply(shared). �g.GROUT s
l
Irri aiion FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: b fit. fit. �L �K �
Monitoring Recovery ft. ft. 6,
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test C]Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG`attach Additional sheets if necessary)
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM I To DESCRIPTIO color,hardness,soil/rock type,grain size,etc
,1 6 fL 2, fit. Clay 61t .-Gu r
4.Date Well(s)Completed: '-$ 2i Well ID# '� ft. 65 fit. �I'rtAt he
ft. ft.
5a.Well Location:
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
M39� Frtseeve- Q,. IUe��NC, .297(1J ft. ft.
Physical Address,City,and Zip _ ft ft. t,;iJ
i21.REMARKS
Rt 64Jt33 rI ':�:F �� W
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Certification: y
S° (G 143.6246P9-*N g10 Sto' L40-97015(4Z W l� •�- zl
6.Is(are)the wells) _ Permanent or Temporary Signature ofCerctfied Well Contractor _ Date
By signing this form,l hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or DAPU wish 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
/f this is a repair,fill out known well construction information and esplain the nature of the copy of this record has been provided to the well owner.
repair tinder#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
9.Total well depth below land surface: 05 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffereni(example-3 a 200'anyd�2@100') construction t0 the following:
10.Static water level below top of casing: O C) (ft.) Division of Water Resources,Information Processing Unit,
{f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: L S (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
0 , A above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: L-O"1 Ck 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 27699-1636
13a.Yield(gpm) Method of test: i%IQ�. COf1I'Gt IhQ 24c. For Water Suably&Iniection Wells: In addition to sending the form to
the address(es) above, also submit'one copy of this form within 30 days of
f_13b.Disinfection type: On Amount: -lI -6 b S completion of well construction to 4he county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 4 Revised 2-22-2016
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