GW1-2021-07910_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Vontractor Information:
'."'V -14.WATEltZ0NE&;rr_.
Well Contractor Name FROM TO DESCRIffION
oft.
17-1 it.
o ft. ft.
fil
NC Well Contractor Certification Number
JU i-M-jF IEFCAgING fforlhultPeasid':*el!s�a SI-1-e
' FROM TO DIAMETER TMATlE ikQ) SWe '
in.
Company N4me 'L ft.
16.INNER'CASING DA
FROM TO I DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: O?rl I I
List all applicable well construction permi (i.e.U7C,County,State,Variance,eicJ & ft. in.
T
3.Well,Use(check well use): ft. ft.
47.�SCREEN
'at�upply Well:
FROM TO DIAMETER SLOT SITE THICKNESSMATERIAL
ff Agricultural OMunicipal/Public ft. ft. in.
:)Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
]Industrial/Commercial 13Rcsidential Water Supply(shared) 1&GROUZ-
7.11higation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft �2&
3Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge []Groundwater Remediation
:) _19.SANDIGRAVEL�PACK,(if�mpolicabl6)-
Aquifer Storage and RecoverySalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
)Aquifer Test OStormwater Drainage ft. ft.
:)Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer -`,20.-D ...... -LOG_(attach'additional sheets-if n&ess"
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRUInON(color soil/rock
,hsrdness�soil/ ck in size,etc.)
ft-
4.Date Well(s)Completed: 202/ Well ID# ft.
5a.Well Location: ft. ft.
'S ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ke 6'a ft. ft.
Physical Address,City,and Zip ft. ft.
`21.,REhIARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if'well field,one latflong is sufficient) 22.Certification-.
N W
a"6.Is(are)the we11(s)E Permanent or OTemporary Signature ofCcrtifie J�k dVcll CZintr6ctor 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: OYes or ONo with 15A MCAC 02C.0100 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 1 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 depth below land surface: 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list an depths Y-differeju(example-3@200'and 2@100) 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"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection 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: 14 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,?Pnderground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 21699-1636
13..Yield(gp.) Method of test: 24c.For Water Supply&Injection 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: A/ Amount: jl 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