GW1-2021-07046_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: t.
14.WATER ZONES � r
Well Contractor Name FROM TO DESCRIPTION
ft. �a t. rSam
ft. ft. I
NC; Contra r Certification Number 15.OUTER CASING for multi-cased,wells OR LINER if a licable OM TO DIAMETER THICItNESS MATERIAL
1 ft. l� ft. l in.
Company Name
,� 1 J 16.INNER CASING OR TUBING(geothermal closed-loop)
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
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
]Agricultural [DMunicipal/Public ft. aZ tt. in. 1� VCR
:-]Geothermal(Heating/CoolingSupply) Water Supply(shared)
18.GROUT.. .n
Industrial/Commerc al pp y) gResidential
Residential Water Supply(single)
tt. it
_ hn ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: b ft. 2QO ft. t kv
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge nGroundwater Remediation
19:SAND/GRAVEL PACK if appiicahlc
Aquifer Storage and RecoveryISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_ Aquifer Test Stonnwater Drainage D,ft. ft. C r Y
Experimental Technology �ISubsidence Control a- 0 tt. L- U ft. J
in. N (\ 5
Geothermal(Closed Loop) nlTracer 20.DRILLING LOG(attach udditIonal sheets' neccssar
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type rain size,etc.)
ft. '1 ft v.,75 O 1,
4.Date Well(s)Completed: ` ' Well ID#
5a.Well Location: p
sU.l\/1 CYl t� ft. tt `�C L G a
Facility/Owner Name ►�//\� Facility
{ID#(ifaapplicable)Q 'I ft. ft. rU h a n
ft.
Physical Address,City,and Zip
r 1 21.REMARKS 1 t t� LIU W. >
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
rf well field,one lat/lon is sufficient
/(� gg ) 22.Certification:
:rlj 1 I • ©J-1 N a . Dui" W r
Lb_.31,,�
6.Is(are)the well(s)JDPermanent or F7ITemporary Signature of ified Well Cobtractor Date
���[[[ By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: EIYes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information d explain the nature of the copy of this record has been provided to the well owner.
repair under 421 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: Inan SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: d 1 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiereiu(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: Sao! (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"�+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the forth to the address in 24a
above, also submit one copy ofthis form within 30 days of completion of well
12.Well construction method: 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: Ny I a 24c.For Water Supply&InieI tion Wells: In addition to sending the form to
i III the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount:Y4 CA4 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