GW1-2021-07047_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
\till t
Y 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Naa ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'wells OR LINTER(if a licable
\^t```\\��� FROM TO DIAMETER THICKNESS MATERIAL
is I a)o Ll Q
Company Name
4� ` `�� 16.INNER CAS1N OR TUBING m cotheral closed-too
2.Well Construction Permit#: 1 ` FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) tt. 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. aca ft. in. (31�) u PAC,
__:Geothermal(Heating/Cooling Supply) Pesidential Water Supply(single) tt. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. a0 tt. h n; COV {�
:I monitoring Recovery ft. �.J ft. ,e-
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK lfapplicable)
Aquifer Storage and Recovery rlISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:)Aquifer Test DStormwater Drainage ORO
Experimental Technology Subsidence Control
Geothermal(Closed Loop) ITracer 20.DRILLING LOG(attach additibnal sheets if necessar `
Geothermal(Heating/Cooling Return) []I Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rocka grain size,etc.)
Qft. ft.
4.Date Well(s)Completed: lX— u—1 Well ID# ft, ft.
5a. ell Location: ft. ft. n
A p
o�Ce S,1(rm� V11,
ne Facility/Owr Name Facility ID#(if applicable) ft. ft. v Sa L ,^
I � ft. ft• �,[�rip �s es�
Physical Address,
/City,andZip
�ook 21.REMARKS
County T Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one(la�dlong is sufficient) (�(� 22.Certification' 1t• a
D Jq
6.Is(are)the well(s) 'Permanent or EITemporary Signature of Cer ed Well Con for Date O(
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: r1Yes or o with 15A NCAC 02C.0100 or 15A NCAC 01C.0300 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information a7,dd explain the nature ofthe 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: 6 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: D (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferew(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: i� (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 Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: ` above, also submit one copy of ithis form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.).) construction to the following:
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: mv 1 24c.For Water Suaaiv&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: I Amount: 3 t�Z 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