GW1-2021-07362_Well Construction - GW1_20210921

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information: i
14.WATER ZONES
WellCoatr9ctorName FROM TO DESCRIPTION
[t. ft.
3/70d? M fL
NC Well Contractor Certification Number 15.OUTER CASING for rnalti-cased wells OR LINER'if 60
ticable
FROM TO DIAMETER THICKNESS MATERIAL
L�.I1 M,�f D�/✓G//�'"t^7l i-/1 c.• ih ft. 6� fL in.
Company Name" = (/
16.INNER CASING OR T BINGf2cotherrual closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
Livi all applicable well construction permits(i.e.U1C,County,State, variance,etc) fL ft. In.
3.Well Use(check well use): ft. ft. in
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agicultural ❑M cipal/Public fL ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEME TMETHOD&AMOUNT
Non-Water Supply Well: ft. 4
o0 ft. WI� a
❑Monitoring ❑Recovery ft. ft.
Injection Well:
iL ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK teapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL fL
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets:if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM ft. ft.TO DESCRIPTION color,hardness,soll/rock s etc
4-Date Well(s)Completed: —a , 0��ell ID# ft. ft.
Sa.Weil Location:
7—
FL rL 1
�•.ti n (l,ol /ice24
Facility/Ownei'ame Facility 1D#(ifapplicabie) ft. ft.
�3y�, 5�,�'�,2.. C�• ,L�.'/.T�� 272�5 h rt.
Physical Address City,' , zip ft fL
, 0
21.REMARKS
County Parcel identification No.(PiN) �� "'�� Gre! �+�✓
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wellfield,one tattlong ilsJsuf?fici)pt) �f A p 22.Certification:
fw
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signature of Certified Well C for Date
By signing this form,I here certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a coP),
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or art 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 construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifd fferent(example-3®200'and 2Q100�
10.Static water level below top of casing: (ft.) Information
For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit 1617 MSC,Raleigh;NC 27699-1617
Ifwater level is above casing,use"+'
11.Borehole diameter: (in,) 24b.For Injection Wells:Copy',to DWR,Urtderground;pjection Control(RUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copyto the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Oroducine over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: t�y Amount: �907•
a
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018