GW1-2021-07017_Well Construction - GW1_20211025

N,<RUCTION RECORD GW-1 For Internal Use Only:
P.,1
ell Contractor Information:
14.WATER ZONES. !
Well Contractor Ame FROM TO DESCRIPTION
ft. 2 ft.
\�3 Pr ft. J ft.
NC Well Contractor Certification Number ` Is.OUTER CASING for multi-cased"wells OR LINER if a licable
�I�1�t FROM TO DIAMETER THICKNESS MATERIAL
V Vlil l 1 I` t` ft. 2 ft. in. Y f h V �/
Company Name V
�, `,�j fiNEWCASING OR,TUBING cothermal closed-1 o
2.Well Construction Permit#: (-7�1(�\ "I-JlT'TI FROM TO DULMETER 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. I in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER __. - ... - -SLOT SIZE THICKNESS MATERIAL
Agricultural []MunicipaUPublic �) ft, It. in.
o� , [)1�P LAO pV(C_
Geothermal(Heating/Cooling Supply) 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: 0
ft, ft. U _
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(ifappikable
Aquifer Storage and Recovery E]ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:,)Aquifer Test OStormwater Drainage DO ft. �� ft. a r
Experimental Technology QlSubsidence Control ft. ft.
RGeothermal(Closed Loop) FnITracer 20.DRILLING LOG(attach additional sheets if necessi"
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
ft. R ft. 1
4.Date Well(s)Completed: v Well ID# ft. t ft.
5a.Well Location: ft. ft.
�Inl � ft. ft. `1��
F�aciiilliitty/OwnneerName �/ FacilityfInD##((iifa,,pplicable) I ft. ft.
�C.)�.J C\ ���1-r[61Y 11[i f11 ft. ft.
P�s1icahA^ddress,City,and 2ip
M4` `bc 21.REMARKS
County Parcel Identification No.(PIN)
Information r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latt/lloong is sufficient) p�Q (�(�(� 22.Certification:
�5D Q J,D�LP N L Ob �� qq W e 1\
6.Is(are)the well(s) ermanent or rlITemporary Signature o eitified Well Co actor 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: EIYes or [yNo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constriction 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 421 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 fdijjereni(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+("n 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
.�- above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: rn�G I V J I� construction to the following:
(i.e.auger,rotary,cable,direct pushy 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: Nm6kacl 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: N � 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