GW1-2021-00283_Well Construction - GW1_20211213

ZVEa L CONSTRUCTION RECORD (GW-1) For Internal Use Only:
3 1.Well Contractor Information:
3C r'r y (tea,'{-b n S 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
��57 Aft. 190 ft 1 4Ak
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a livable
KI YADN WELL COMPANY,INC. FROM TO DIAMETER THICKNESS MATERIAL , n
Company Name M Q / 16.INNER CASING OR TUBING eothermaI closed-loop)
2.Well Construction Permit#: V ( W FROM TO DIAMETER THICKNESS MAATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. c/_ ft• G� in. Sp'a r A/C-
3.Well Use(check well use): ft' ^7 V k' / in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL.
❑Agricultural ❑Municipa]/Public k. ft. in. .�
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EWLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Dft' S k' 46 to Atol eov at S 65J
❑Monitoring ❑Recovery S ft. a J4 fL 3 p
Injectiou Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPL.ACEMM,NT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. k.
❑Experimental Technology ❑Subsidence Control k. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soiltrocic e, in sae,etc.
❑Geothermal(i-Ieatinp�Cooling Retum) ❑Other(explain under#21 Remarks)
6 ft. . - ft.
1 4.Date Well(s)Completed: I / 41 Well ID# LIS ft. 1043 ft. 6ra^t Ir
5a.Well Location: Phone #f a 2y SO( et 3�F ft ft.
v . ' fL fL
V Gh
Facility/Owner Name Facility ID#(if applicable) ft. ft. DEC 1 3 2 0 2'
`/Q.M...VW:f ''",'4 ft. ft. -
�( Physical Address, ft'IA/J'I/f eJ 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(ifwell field,one lat/longis sufficient) 22.Certification:
r 26 63N _3j w 4d5F 1L � 10 {1l
S 6.Is(are)the well(s): ermanent or ❑Temporary Signature of Certifet Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or &0 1 SA NCAC 01C.0100 or l5A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fdl out known well construction information and explain the nature of the ofihis record has been provided to the well owner.
repair under#21 remarks section,-)r 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 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary. T I
tr drill�-d: ` 24.SUBMITTAL INSTRUCTIONS
""1 9.Tot0 well depth below land surface: /04 3 (ft.) 7
A) Fce r•r_Itiple wells list all depths ifdifferent(example-3@200'and 1®1000 Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
;''�10.: atic water level below top of casing:_ _ iC�) (ft)l Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
1.Borehole diameter. U/ (in.) Bit Off: _ �- J 24b.For Injection Wells: Copy to DWR,1 aderground Injection Control(RUC)
r} Program,1636 MSC,Raleigh,NC 27699-16: i
AIR ROTARY �
12.W,il eon ,tr.lction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 41"1
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed 0�
LJ
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 ivISC,Raleigh,P-.27699-1611
13a.`[field(gpm)_ Metiird of test: Q/�p
13b.Disinfection type: 70%HTH Amc.mt: q OZ GATE SITE VISi rED::
VISITED BY:_1L�
Form GW I North Carolina Department of Environmental Quali;. 7ivision of Water Resources Revised 6-6-201 s