GW1-2021-07053_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well
Contractor Information:
14,WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
NC Well Contract r Certification Number 15.OUTER CASING forioulti-cased wells 0 t LINER if a licable
11; FROM TO DIAMETER TffiCK`N_E,SS+'\ MATERIAL
"\ ft, 2 ft. Z:, in' SLTI�'1 V -4 L
Company Name v
16.INNER CASING OR TUQING 'eothcrmal closed-loop)
2.Well Construction Permit#: I-\ C55 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. VIC,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 in.
Q 1a v
:)Geothermal(Heating/Cooling Supply) Residential Water Supply(single) —1 ft. f[. in. ,
Industrial/Commercial lResidential Water Supply(shared) 18,GROUT.
I1Ti ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Oft. of C) ft. �t�L�t J� Lk _ \
Monitoring Recovery ft. tt. Yj
Injection Well:
Aquifer Recharge Groundwater Remediation 19•SAND/GRAVEL PACK(lf a licable
Aquifer Storage and Recovery ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
__.Aquifer Test IStonnwaterDrainage � tt. je7 ft \3,
Experimental Technology []]Subsidence Control
Geothermal(Closed Loop) ITracer 20.DRILLING LOG(attach additional sheets if necessar '
FROM TO DESCRIPTION(color,hardness,soil/rock type,gmin size,etc.)
Geothermal(Heating/Cooling Return) _I(Other(explain under#21 Remarks) ft. ft.
^ ��
4.Date Well C Q s)Completed:� Well ID# ft. 'o`� ft. r
5a.Well Location: A I Ift. 1 Cl ft. 01 ;As
WOIGZ- C Q
rFacility/Owner N/ampe � ��A Facility ID#(if applicable) a- ft. 3� ft. -k-a r1 c�..
W � 1`'(C\A D Wy , Jt�
Phy 'cal Address,City,and Zip ft. ft.
C rna oa o►l 131 g 21.REMARK, .
IN
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `r'o
(ifwell field,one lat/long is sufficient) 22.Certification: c�rrt,O�
4� CP—u
6.Is(are)the well(s) Permanent or OTemporary Signature of Certi d Well ContractoiV 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: OYes or !No with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information an explain the nature of the 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: ?� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ✓� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiQerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: I CP (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: LP (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
�`���,►l above, also submit one copy of this form within 30 days of completion of well
12.Well construction method etc.) � 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: pyYYIP 24c.For Water Supply&Injection Wells: In addition to sending the form to
1� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: C 1 Amount: �A Z completion of well construction to the county health department of the county
where constructed. p�
f
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016