GW1-2021-00316_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
1 )
CA,Y►�\r I �P4 l r L 14.WATER ZONES ¢
Well Contractor N me FROM TO DESCRIPTION
O YJ -^�ft. 3 ft. rc& rcy ci
ft. 5,X. rt roc�
NC Well Contractor Certification Number 15.OUTER CASING'for multi- sed wel OR LINER if a licable
' `��r� J�r 1 I 1 i`�� FROM TO DIAMETER THICKNESS MATERIAL
fl/If �/i/ CJ I , ft 1 ZD ft. !I in.
Company Name r�
5iF a�� —fJU 16.INNER CASING OR TUBING' tn eotheral closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. VIC,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 [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) gResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT:,
_ In'1 ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. o
:)Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19.
Aquifer Storage and Recovery 0ISalinity Barrier FROM SAND/GRAVEL PACK 1eMATERIAL EMPLACEMENT METHOD
:)Aquifer Test CIStonnwater Drainage
Experimental Technology n]Subsidence Control
Geothermal(Closed Loop) FnITracer 20.DRILLING LOG(attach additional sheets if rtecesshi `
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
_I Geothermal(Heating/Cooling Return) _.i I Other(explain under#21 Remarks) D ft. ft. S r
',y u
4.Date Well(s)Completed: /D-3 -2z4—Well ID# ( ft. ft. A �k
5a.Well Location: ft. 2 ft. a h C )�
Signature- 4mP (3Ids fL V ft Sun l e et
Facility/Owner Name r /�Facility ID#(if applicable) � Oft � ft.
�0 !►lri1�`� S 1�1 91A1 1°S IXCPI�
Physical Address,City,and Zip ft- 163
6 2 ft. A e�y;., r i 1_
arAel/ 0&g1-L)1- (n V6�ra6o 21.REMARKS ✓
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification r* °
6.Is(are)the well(s) Permanent or (Temporary Signature of C fiedd Well C tractor; 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: [(Yes or No with 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards,and that a
If this is a repair,fill out known well construction information d 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages i£necessary.
drilled: SUBMITTAL INSTRUCTIONS
P /
9.Total well depth below land surface: / LO J2 (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
i
11.Borehole diameter: (in. I
24b.For Iniection Wells: In addition to sending the forth to the address in 24a
above, also submit one copy of this form within 30 days of completion of well-
12.Well construction method: construction1
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) Method of test: ) 24c.For Water Supply&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 1 T 1+ Amount: L 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