GW1-2021-00312_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor NamFROM TO DESCRIPTION
ON ft
VC y . � ft. vN so a'YA
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER(if a Iicable
FROM TO DIAMETER THICKNESS MATERIAL.
lI VV VVVV`"` V V ` ft. ft in.
Company Name 1
16.INNER CASING OR TUBING eothernral closed-loop)
2.Well Construction Permit#: 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. f, in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural �Municipal/Public ��ft. 3oft. in. I p�� 'k Vc-
Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18,GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. QC- ft. Y1n /
Monitoring Recovery ft. ft. u f.
Injection Well:
ft. ft.
_ Aquifer Recharge DGroundwater Remediation 5-6 S
19.SAND/GRAVEL PACK(if applicable)
_ Aquifer Storage and Recovery MISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [IStormwaterDrainage 01O ft. o ft ^� < ur
Experimental Technology []]Subsidence Control ft. ft. �f
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessa
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) ]Other(explain under#21 Remarks) � ft. � ft.
50 l
4.Date Well(s)Completed: Well ID# ft. ft. so
Sa ft.
.Well Location: �,, j�j ft. CX-1
�S�Cgh(1hw �A gl , llV�t�&C 6 ft. ft.
0 T-0-n
Facilivpbwner Naccm��e�� Facility II(D#(if applicable) ft. ft.
Pheys al Address,City,and Zip ft. ft. O E C 2.® 2021
21.REMARKS
County Parcel Identification No.(PIN) '' ? ,d
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) p 22.Certification:
Ss . 3�a 9UON -Lou-�23R W O Q
6.Is(are)the well(s) ermanent or C ITemporary Signature of ified Well Cooractor Date
T 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: E)Yes or o with 154 NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Constniction Standards and that a
If this is a repair,fill out known well construction information nd 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
)�
� t
9.Total well depth below land surface: ,� (ft 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffereni(example-3@,200'and 2@I001 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 Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: mA 2
` , Yua above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) U
construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Vidl fA 24c. For Water Suonly&Iniection 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: 1 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