GW1-2021-07009_Well Construction - GW1_20211025

W>;.P LL CONSTRUCTION UCORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Q 1 (/ V 14.WATER ZONES
Well Contractor Nan
a FROM TO DESCRIPTION
t. ft. U
a163- - ft. ft.
NC Well Contractor CeerrtiScati n Number ^ l 15.OUTER CASING for multi-eased wells OR LINER if a livable
- t,/`9 ' I / /r 1 / �'f/I FROM fL TO ft. D TER in. THICK MATERIAL
Company Name J /1/ C L ` 4 l 1/G
j 16.INNER CASING OR TUBING nt eotheral closed-loop) V
2.Well Construction Permit#: 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. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:.)Agricultural [DMunicipal/Public 55ft. ft. in. ut�0 ve
� (f
Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft. ft in.
Industrial/Commercial tResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 10 ft. ' 6 ft. e11 hn) o UV Y41w
Monitoring DRecovery ft. ft. 1� !; )_
Injection Well: o p
ft. ft. o e Lt
- Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if a' licable
Aquifer Storage and RecoveryISalinity Banner FROM TO MATERIAL EMPLACEMENT METHOD
:)Aquifer Test (®IStonnwater Drainage 0ft. 6 ft. o ol,(V Yf/1 V)r
I Experimental Technology E]ISubsidence Control
Geothermal(Closed Loop) QlTracer 20.DRILLING LOG(attach additional sheets if necessa'
FROM TO DESCRIPTION(color,hardness,soil/rock type,gnin size,etc.)
Geothermal(Heating/Cooling Return) [ (Other(explain under#21 Remarks)
4.Date Well(s)Completed: L/ 9Well ID#
5a.Well Location:
13ft. ft. 1 L c l a
Facility/Owner Name Facility ID#(if applicable) S ft. ft. Y�
o on Wed W PDseboyo rvc a , ft. ft.
ft. ft.
Physical Address,City,and Zip Q� J
a rn aSdil II/J� 01 t' 343 /D 2L REMARKS 1
County Parcel Identification No.(PIN) inn
.,3tmn pro
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) r 22.Certification:
35°a?l 7 N 3 30, /9)3 w
6.Is(are)the well(s)IITQPermanent or [(Temporary Signature of C ed Well Contract Date
77�-"" By signing this form,1 hereby certify the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: rOYes or o 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 and 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: CP D (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di fferent(example-3@200'aand 2@)00') construction to the following:
10.Static water level below top of casing: U (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: n.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method to Y above, also submit one copy of this form within 30 days of completion of well
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) 10 Method of test: 19 IJAJ 01 24c.For Water SunDIV& Iniection Wells: In addition to sending the form to
�" the address(es) above, also subinit one copy of this form within 30 days of
13b.Disinfection type: ff TH Amount: 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