GW1-2021-07442_Well Construction - GW1_20211006

1.Well
//Contractor Informatio/nJ: t�
C �GU P�It I / � 1\ .WATER ZONES
OM Well Contractor Name TO DESCRIPTION
c�C� Q �r�\�� O ft. ft. 5
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3 �` t0 �\0P /,'o ft. /eg ft. s'
NC Well Contractor Certification Number \0� S6,
J 15.OiTTER CASING for multi-cased wells OR LINER if applicable)
nOa /_ ��I' nU�� \�r� Q FROM TO DIAMETER THICKNESS MATERIAL
1 N (tJ �C fN 1 tt. ry 3 ft. in. `(j w I Company Name /� ^ / 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: U-ud- OS -)qG 4-ZU Z( FROM TO DIAMETER THICKNESS I 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 I MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in
❑Geothermal(Heating/Cooling Supply) UR"eesidential Water Supply(single) tt. ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. U ft. !/
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. fa
❑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 TO DESCRIPTION(color,hardness,soil/rock type,grain size,eta
4.Date Well(s)Completed: '2 Well ID# Z
5a.Well Location: ft. Z S ft. ��A �.
8``Ckn CM,' A ft. ft.
Facility/Owner Mun ( Facility ID#(if applicable) ft. ft.
a I /that ale w d- y C ft. ft.
Physical Address,City,and Zip a 7149
ft. ft.
21.REMARKS
County �l Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
22(if well fiiel( i d,one lat/long s sufficient) q 22.Certifies'on•
�.JS�"{ 1 t3 J. I!N L L\D"1�I���. ILO W �S L
6.Is(are)the well(s):Gwrmanent or ❑Temporary ature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or 10 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
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 on the back of this form.
23.Site diagram or additional welOetails:
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: I24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: a ' (ft.)
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
2� 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
/ Program,1636 MSC,Raleigh,NC 27,699-1636
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12.Well construction method: 24c.For Water Supply and O en-Ioo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where instal ed
FOR WATER SUPPLY WELLS ONLY: (�) 24d.For Water Wells producing o i er 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) I Method of test: tom/I G Permit Program,1611 MSC,Raleigh;NC 27699-1611
13b.Disinfection type: ��( I Amount: �.
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