GW1-2021-07624_Well Construction - GW1_20210903

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
sI b fa a 'in 14 WATER ZON&S .. ,.
Well Contractor Name FROM TO DESCRIPTION
NC Well Contractor Certification Number lar.OUTR'CASMG ttii inoln cased weti;ORGINER lia llcable "
1 /� � I r D FROM TO DIAMETER THICKNESS MATERIAL
1 t,/c_4—c•t' t j 1' L�-c-Cis �it,T fL
/L/q ft. , in. ,./ c ✓
Company Name
.16.INNER CASING OR T[TBING(geothermal cldsed•loo _
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(ie.UIC,County,State,Variance,etc.) ft. tt. In.
3.Well Use(check well use): R' R in.
.Water Supply ell: 17.:SCREEN ,
FROM TO DIAMETER SLOT SIZE TmCKNESS MATERIAL
Agricultural E3Municipal/public 0 ft,
Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft, ft, in.
industrial/Commercial [)Residential Water Supply(shared)
l&GROUT
ltri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: IL t j �t
Monitoring D Recovery fL ft.
Ii�ecdon Well:
AfL ft.
quifer Recharge Groundwater Remediation
19.SAND/GRAyEti'PACH rif a_liceble
J.iAquifer
ftAquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Test OStormwater Drainage . fL
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach'additional sheets if Geothermal Heatin Coolin Return Other(explain under#21 Remarks FROM To DESCRIPTION color,ftEe5soilf..k type,grain size,eta
ep ft ft. 6
n
4.Date Well(s)Completed:—1 = Well ID# ft. ft. /�
5a.Well Location: �' ft' p{ 2.5
t.
Facility/Owner Name FacilityID#(if applicabie) t' G
MW
Physical Address,City,and Zip R R-
1 mac. IX-G B1.REMARKS.
County Parcel Identification No.(PIN)
0�5
56.Latitude and longitude in degrces/mYnateslseconds or decimal degrees:
(if well field,one lat/long is sufficient) 22,Ce lion: ' O�((,30,,1RCje+
�5.9s03/ N -7 /�,�S� w ��� V r
I&M, r r
6.Is(are)the wett(s) attent or Temporary rBr� Certifi
rm ed e 1 Comma r Uatc
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an eidsting well: 13Yes or OVi with 15A NCAC 02C AI00 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary,
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depot below land surface: /l/"/ (ft.) 24a,For All Welts: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3©200'an 2@1001 construction to the following:
10.Static water level below top of casing: 3 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above acing,use"+^ 1617 Mail Service Center,Raleigh,NC 276991617
11.Borehole diameter: (0�6 (in.) 24b.For Iniection Welts: 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 m rvl construction to the following:
(i.e.auger,rotary,cable,dire method:thod:t push,etc.)
Division of Water Resources;Underground Nection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) _ Method of bit: R/A2yj,,*'t k2de.For Water SnuDly&Iniection Wells: In addition to sending the form to
e addtess(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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016