GW1-2021-00318_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) .For Internal Use Only:
1.Well Contractor Inforlmation:
r 14.WATER ZONES
Well C ntractor Nartfre FROM TO DESCRIPTION
3_ l,V_
SoLrA
ft. ft. j
NC Well Contrac r Certification Number
r 15.OUTER CASING for
-cased wells) LInR(if alcbleRt TUFROM TO DIAMETER ( ESS MATE RIAL
l v in.
Company Name
16.INNER CASING OR TUBING eolhcrmal closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) I ft. f ft. in. SC t_
3.Well Use(check well use): ft. it. in.
Water Supply Well: 17.SCREEN:
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
_,Agricultural DMunicipal/Public :29/�ft. �� ft. in. ©Q, �5CWAQ PY(-,
Geothermal(Heating/Cooling Supply) _Residential Water Supply(single) ft. ft. in.
Industrial/Commercial JoResidential Water Supply(shared)
18.GROUT
_ 1 1ri ation FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL-PACK if applicable)
_' Aquifer Storage and Recovery rlISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_,Aquifer TestIStormwater Drainage 2o
ft. 2.5
C j2 ft-
2n
Experimental Technology Subsidence Control
Geothermal(Closed Loop) (Tracer 20.DRILLING'LOG(attacli'additi6fihi sheets if necessa '
BGeothermal(Heating/Cooling Return) ]IOther(explain under#21 Remarks) FROM I TO DESCRIPTION(color,hardness,soil/rock type,gnin size,etc.)
O ft. ft.
4.Date Well(s)Completed: r Well ID# ft. a ft.
5a.Well Location: ft. /�,-ft.
Make 5 mar ayft. / ft.
Facility/Owner-Name Facility ID#(if applicable) ft. ft.
�.x. �Cal'.
IVO
Physical Address,City,and Zip {� - ft. f
21.REMARKS County Parcel Identification No.(PIN) DEC 2 ® 2 O 21
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
Q 2�(, 2,� 22.Certification: t •,- atr,� r ,� "I 1
O -1 • J o 1 'Igo 7- to W N _
Oeo W Ia9-
6.Is(are)the well(s) Permanent or [(Temporary Signature ofCe 'red Well Contfctor! 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• Dives or/16No with 15A 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 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-I.is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: r SUBMITTAL INSTRUCTIONS
' f
9.Total well depth below land surface: �5 /ea7- (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: 15 (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 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: 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: to p 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �(7. Method of test: )` 24c. For Water Supply&Infection 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: / completion of well construction bto the county health department of the county
where constructed.
Fowl GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016