GW1-2021-00248_Well Construction - GW1_20211213

WELL_CONSTRUCTION RECORD(GW-1) For Internal Use Only:
R? 1 1 e. -ontractor Information:
t C 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
O fL I-AT3e'_ GrAV n
fL fL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased Wells OR LINER if a livable
f (�/� FROM TO D AETER THICKNESS 1'IA7'RRIAr,
ft.
PVC
Company Name 16f.INNER CASING OR TUBING' eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable weft construction permits(i.e.UIC,Countv,State, Variance,etc.) ll
1
3.Well Use(check well use): m C L
Water Supply Well: 17.SCREEN
y pP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
r:❑Agricultural ❑Municipal/Public �l1tL O fL in. .� � VG
I tt LlGeothermal(Heating/Cooling Supply) pe.idential Water Supply(single) {L {L in
t ❑6ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
ItIrriation ❑Wells>IOQOOOGPD FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT, r❑
Non-Water Supply Well: it ,,O It.
l f
+K OMonitoring ❑Recovery ft. tL
`. Injection Well:
ft iL
❑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 O it It A. Po(/(
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets it necessary
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
TO DESCRIPTION(color,hardness,soiUrack e, in size,etc.)
ks) tL O fL AA tA C I A
4.Date Well(s)Completed: Well ID# ^Lo
iL AR ft ornoSe-
5a.Well Location: ^ fL •Ll O
ft. It.
Facility/Owner Name Facility lD#(if applicable) ft. ft.
77 21 UW Y 49 60US A-h O.C. 17d e1.1 ft. ft.
Physical Address,City,and Zip ft ft.
P\► \ 21.REn4ARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r,
(ifwell field,one lavlong is sufficient) 22.Certification:
3'S. L6��66 N -77. 67 863_W
6.Is(are)the well(s): eranent or ❑Temporary Signature of Certified Well Contractor Dale
m
_� By signing this form,I herebv certifv that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or �1V0 15A NCAC 01C.0100 or 1 SA NCAC 01C.0200 Well Construction Standards and that a copy
Ifthis 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 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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 8 (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@1001
// 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: b (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If ivater level is above casing,use"+" I
24b.For Injection Wells:Copy to DWR Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NTC 27699-1636
12.Well construction method:MSZV kryy` 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to 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 producing over 100,000 GPD: Copy to DWR,CCPCUA
J� Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) a 0 Method of test: 1'11 f
13b.Disinfection type: C Amount: 3 oZ..
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018