GW1-2021-00068_Well Construction - GW1_20211109

F 111117 VI111
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information-
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
NC Well Contractor Certification Number I&OUTM CASIM6' nI[t;cesw we OR LINER ncable
V vt l I • / y to r/�f� 1 / FROM TO ROM.TER TffinCSnNBSS MATERIAL
ft ft. in.Company Name 16
16.INNER CASING OR TUBING' eothermal closed-too
2,Well Construction Peiinit#: FROM TO DtA AKIM I TfUCKNESS MATERIAL
List all applicable well construction permits(i e.UIC,Count),,State,Variance,etc.) ft• R• ith
3.Well Use(check well use): ft. ft. is
Water Supply Well: M SCREEN
FROM TO DIAMETER SLOT SIffi I TIUCKNESS MATERIAL.
f Agricultural [3MunicipaUPublic g, ft, in.
Geothermal(Heating/Cooling Supply) _ iderltial Water Supply(single)
ft. ft. in
Industrial/Commercial [Residential Water Supply(shared) 18 GROiPr
71hrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft
Monitoring Recovery ft. M
Infection Well:
A Utter ft. ft.
q Recharge C]Groundwater Remediation
19.SAND/GRAVBL PACK Ifcable
Aquifer Storage and Recovery DSalftlity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology DSubsidence Control
Geothermal(Closed loop) E3Traccr 20.DRILLING LOG(attach additional sheets if necessary)
1"Geothermal Heatin Co ling Return) rjOthcr lain under#21 Remarks FROM To DESCREMON color,hardness,soW—k d:m,etc-
ft. ft.
4.Date Well(s)Completed: - 'n( Well ID# ft. M
go. ell Location: R' ft.
_ Md G ([�, M ft. A -
Facility/Owner Name n Facility M#(if applicable) ft. ft.
'V 5(O /t� 1"Q�i� 1 � C.I1 �Ol ft ft.
Physical Address,City,and Zip ft. MSECTION
eejaoax
21.
Codnty Parcel Identification No.M • t�� -L
5b.Latitude and longitude In degreestminutes/seconds or decimal degrees: Ccr--.
(if ell field,one latllong is sufficient) 22. rtification:
ji— —AOU
w
6.Ls(are)the well(s)Q4manent or 0TemporM7 Signature of Certified We Contractor Date
4 signing this form,I hereby cerh y that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: es or ON. with 15A NCAC 02C.0I00 or 15A NCAC 02C.0200 IW&I Construction standards and that a
If this is a repair,f ll out Amown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair raider#21 remarks section or on the back of this form. 213.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�W-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also,attach additional pages if necessary.
drilled:
n
9.Total well depth below land surface: "1 (fL) 24a.For AU Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3©2 'and 2 !00') construction to the following:
10.Static water level below top of casing: q= (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. 6 �q 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: above,also submit one copy of this folm within 30 days of completion of well
(i.e.auger,rotary,cable,dirt push,etc.) construction to the following
Division of Wafter Resources.Undergl+oand Injection Coafaol P-8--,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 0 Method of test: 24c.For Water SaDDIv&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: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Depamment of Eaviro mental Quality-Division of Water Resources Revised 2-22-2016