GW1-2021-07051_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1. ell Contractor Information:
1�`�u ► r
rm 14,WATER ZONES li �
Well Contractors Nam FROM TO DESCRIPTIO1N
U U3 ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-easetl wells OR LINER if a licable
�� FROM TO DIAMETER THICKNESS MATERIAL
ft. Pa ft. in. SLbq(_ ��
Company Name l�
Q /��( 16.INNER CASING OR TUBING eothernral closed-loo
2.Well Construction Permit#: I D �V 1� 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. tt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural oMunicipal/Public ft. tt.as in.a a) o� s L� Pvc-
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. tt. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT.
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft, rl ft. ��1 _
Monitoring Recovery ft. O� ft.
Injection Well: b
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery rIISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
-.Aquifer TestIStonnwater Drainage aOft. c')(_P ft.
Experimental Technology n)Subsidence Control ft. ft.
Geothermal(Closed Loop) rJITracer 20.DRILLING LOG(attach'additiorial sheets if nccessar)`
FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,ete.)
BGeothermal(Heating/Cooling Return) I Other(explain under#21 Remarks) ft. ft.
n �\
4.Date Well(s)Completed:lX oZ Well ID# "� ft. 1 ft.
—5 a.WelllLocation: ft ft.
R&(J(- 10 ft.
Facility/Owner Name 1^Facility ID#(if applicable) ft. ft.
UcAe U{1X Y tI►c !
Physicality,and Zip ft. ft. `A
J �'I 8u 21.REMARK
Tt 1 V
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:
35a q,_A N J� d' 2A �t) W J6,AAM,(A I
6.Is(are)the well(s)qermanent or OTemporary Signature ofCerti d Well Conti for Date
�( By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EIYes or No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction h formation d explain the nature of the copy of this record has been provided 1a 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-I 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: OC w (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:
10.Static water level below top of casing: C77) (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: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,l Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1v Method of test: vMot 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: Amount: I 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 Resource s Revised 2-22-2016
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