GW1-2021-07006_Well Construction - GW1_20211025

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
LanW'W' ' y' U it 14.WATER ZONES
Well Contuuracc1torNam FROM TO DESCRIPTION
LP t�l�Vl V�� ft. ft. �-
1 ft. 1� ft.
QVA
NC Well Contractor Certification Number 15.OUTER CASING for mull-cased`wells 0 1 LINER if a licable
1. 1
FROM TO DIAMETER THICKNESS MATERIAL
l ` ft. I qL-0 ft. in. I ,
Company Name �� R' \_
16.INNECASING OR TUHINC cothcrntal closed-loo
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
_ AgriculturalMunicipal/Public IU ft. (Wft. in.
:)Geothermal(Heating/Cooling Supply) R
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
Monitoring DRecovery tt. ft. Sb (b ecc
Injection Well:
ft. ft.
_ Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK If,applicablc
Aquifer Storage and Recovery r.IISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
-. Aquifer Test DStonnwater Drainage '-2 N ft. fL v y-
Experimental Technology r.lISubsidence Control
Geothermal(Closed Loop) [MlTracer 20.DRILLING LOG(attach additional sheets if necessary)'
__]Geothermal(Heating/Cooling RReturn) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
(Other(explain under#21 Remarks) O
4.Date Well(s)Completed: ^ Well ID# ft' d� ft' el
Sa.Well Loca'on: ft. ft, e�.�Ca� G
\QI(S 1� ". S� ft. 0 CIS- C
Facnility/Ownner`NLm�e(� Facility
`ID_4(ifapplicable) �j j ft. ft.
— V VIA��A 1 V V ��YJl1� . ':A
Oft. QI u ft. G�C�C- G
CWWC -1
Physical Address,City,and Zip �— -1`-eft' too ft- 1r
\o C\R 3(os \y 21.REMARKS r1�
gglil4J
County Parcel Identification No.(PIN) Mtn
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
�►1g N -191) 2'o,ogg Wlq�t
Sie of C d Well Contract,
Date
6.Is(are)the well(s) Permanent or EITemporary g er
����,,,,ffff 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: rJYes or No with 15A 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 nd explain the nature of the copy of this record has been provided to the well owner.
repair under#121 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: r SUBMITTAL INSTRUCTIONS
^
9.Total well depth below land surface: ,y V (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: '5 (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: t`'^/ (in.) 24b.For Iniection 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:fM 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
i
13a.Yield(gpm) 0 Method of test: i 24c. For Water Supply& Infection 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: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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