GW1-2021-00315_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: --(
J V, 14.WATER ZONES.
Well Con�tractyor�Nam FROM TO DESCRIPTION
<:� l ft. CQ S-ft. fn
ft. ft.
NC Well Contractor Certification Number L
t� 15.OUTER CASING for multi-cased'wells OR LINER if a`licable
�^'`l��t�^ S �fi11`y � FROM TO DIAMETER THICKNE`S�S,-� M�rA'ITERIAL
om �jJ V f 1 l 1'u 4-1 it. n 1 ft. in. h -v 1"VZ_
Company Name O� .
16.INNER CASING OR TUBING'. "e'otherntal closed-too
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. it. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
Agricultural E3MunicipaUPublic �ft. aG ft_ in. .O`a ,r�
J Geothermal(Heating/Cooling Supply) FIResidential
Residential Water Supply(single) in•
__ 9�industrial/Commercial Water Supply(shared)
18`GROUT. '
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. n�1 i a 7a — . -Exi V
Monitoring Recovery O
Injection Well:
ft. ft.
Aquifer Recharge 13 Groundwater Remediation 19.SAND/GRAVEL PACK if'a i;kable
_;Aquifer Storage and Recovery EISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
__'Aquifer Test OStonnwater Drainage '( it• 3 l it• a is
Experimental Technology rJISubsidence Control
BGeothermal
Geothermal(Closed Loop) (Tracer 20rDRILLING LOG(attachadditl'oi it Aceti if h&essa(Heating/Cooling Return) ;(Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type rain size,etc.)
0 ft. A ft. -W C
4.Date Well(s)Completed: ` d.� Well ID# Ci ft.
Q1 ft. a( ft.
Sa.Well(L�ocation1,
�O.AC. (�(�1V�,1�nS Alft. ft. OMA SaPI
Facill�ity/Owner Name C (� Facility ID#(if applicable) '1 S
IVit1 1 V
o � CI �Ct W1 t/;�i� ►—t� A)�My) m ft. ft.
Physical
/Address,City,and Zip ft. ft. 4,
�aCnct 21.REMARKS 1:
County Parcel Identification No.(PIN) 0Lit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlon is sufficient d l�tll
(� g ) 22.Certification: f:;I�y,m`iii�+,v,a
35D 1C1 ,0157 N _1V 3A-S91 W q aLl
6.Is(are)the well(s) Permanent or [(Temporary Signature of CeiLified Well Co reactor 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 Vo 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 1 GW-1 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: 3 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100� 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: (i? (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: MA 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) D Method of test: Dwyv \( 24c.For Water Supply&Iniection Wells: In addition to sending the form to
1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HEN Amount: CY10 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