GW1-2021-00307_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
�1/ t 1 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
,),Q S ft. 50 ft.
ft. ft.
NC Well Contractor Certification Number
\ _ 1 15.OUTER CASING for multi-cased wells)ORLINER if a iicabic
FROM TO DIAMETER TffiCKNESS MATERIAL
111111 VVV 1 v V�/ 1 —I ft. 1.�.� ft. in.
Company Name
no�� l6.INNER CASING OR TUBING cothermal closed-loop)
2.Well Construction Permit#: (JP `1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:]Agricultural C)MunicipaUPublic L�5 ft. 50 ft. rn. QrLAo R�
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT.
_ Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C) ft. Ro ft.
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_ Aquifer Test
I Stormwater Drainage ft. `JV G.y1 fL QM r,
:_ Experimental Technology r]Subsidence Control ft. ft
Geothermal(Closed Loop) r1ITracer 20.DRILLING LOG(attach additional sheets if necessary)"
Geothermal(Heating/Cooling Return) Iother(explain under#21 Remarks) I
FROM ft. TO DESCRIPTION(color,hardness,soil/rock a rain size,etc
nn � ft. � tilt 1
4.Date Well(s)Completed: O( Well ID# ft. I.
CL f1 `�
Sa.Well Location: q ft. � ft- .fan
Facility/Owner Name lJ1 Facility ID#(ifapplicable) Lis Q�(] 5ft- ISO ft-
I''
\ 1�-d e c 60 �WQ�al� A I NL I ft. ft. DEC 2O 20
Physical Address,City,and Zip ft. ft.
21.REMARKS ,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(i`f�w,elll field,one
llat/long is sufficient) 1 22.Certification:
q() /-I t �1 N �0 �o I `� W
6.Is(are)the well(s) Permanent or EITemporary Signature of Certifi ell Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EIYes or 16No with 15A NCAC 02C.0100 or 15A NCAC 01C.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 depth below land surface: 50 —(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'a7nd 1@100� construction to the following:
10.Static water level below top of casing: 1 (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: mil' (in.) 24b.For Iniection 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: Mua W-O'V� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 Method of test: DOMV 1 VA 24c.For Water Supply&Iniecti on 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: Y, Amount: /4 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016