GW1-2021-07043_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14,WATER ZONES t l
Well Contractor Name FROM TO DESCRIPTION
p i ft. s— ft. �
a� /�Vi.�• � it. ft. C lA
nd
NC Well Con ctor Certification Number 15.OUTER CASING for multi cased wells OR LINER(if a licable
� FROM TO DIAMETER THICKNESS MATERIAL
6
J V t ft. 3 ft. I a in. �Jl%4 fC)J PV(
Company Name Y V`/
16.INNER CASING OR TU[i1NG 'cothermat closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN i
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_ Agricultural DMunicipal/Public 3` ft. r ft. t•►a' in. O\� �� 4 O Pc,
)Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
' Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O U
Monitoring ORecovery
Injection Well:
ft. ft.
_ Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if'applicable)
Aquifer Storage and RecoveryISaliniry Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_.Aquifer Test -I]Stormwater Drainage o " r
Experimental Technology r.IISubsidence Control
Geothermal(Closed Loop) ITracer 20.DRILLING LOG(attach additional sheets if necessary)'
BGeothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,gmin size,etc.)
ft. ft, eh
4.Date Well(s)Completed: 51 Well ID ft. ft. li J
ft.
Sa.Well Location: ft.������
�ercFd`C2� �U. .r ft
O .
J ft.
Facility/Owner Name ft. ft.
ft. ft.
Physical Addre 1�,City,and Zip
ft. ft.
4eSUM 1 '� REMARK
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:
--/
3qa % .qp N IS0 -SA-Wq W - c
6.Is(are)the well(s)36,Permanent or CITemporary Signature of Ce fied Well Con 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: Dyes or jdNo with 15A NCAC 02C.0100 or 15A)CAC 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#i21 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 I 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: 35 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100� construction to the following:
t
10.Static water level below top of casing: (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 Infection 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: MIJ6 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) to Method of test: � Y1n 1 f1Cy 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: 7 H 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