GW1-2021-00323_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Co c[o�rpNa a FROM TO DESCRIPTION
Vt� Oft. a ft.
ft. ft.
NC Well Contractor Certification Number h 15.OUTER CASING for multi-cased wells OR LINER(if a lieable
FROM TO DIAMETER TffiCKNESS MATERIAL
Company Name ft. a Oft. a in. SLingo '�V Ci
16.INNER CASING OR TUBING eotherntal closed-too
2.Well Construction Permit#: FROM TO DL+METER THICKNESS MATERIAL
List all applicable well construction permits(i.e. U1C,County.State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:]Agricultural Municipal/Public (D ft. a-�ft in. C) 5,( P\/L
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft.
Industrial/Commercial (Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METH D&AMOUNT
Non-Water Supply Well: O ft. O ft.
Monitoring DRecovery ft. ft.
Injection Well:
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
_ Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft a
Experimental Technology r.1ISubsidence Control ft. ft.
Geothermal(Closed Loop) QlTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock rain size,etc)
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) ft a ft c
4.Date Well(s)Completed: a1 hell ID# ft*
g ft. S
Sa.Well Location:
ft. ft 19 . r\;
1 'V10A ?o4yu oft as ft.
Facility/Owner Name W . 0 r�/ Facility I�D#(ifapplicable) 00 ft. aLp ft. r^kQ� C
W1
Ph&' Idlr�ess,City,and Zip 1,( 2�` ft. ft.
`1�� 153'1-41 -LAU3 zI.REMAR1cS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: DEC 202
(if well field,one ladlon(g is sufficient) 22.Certification:
�
5• 3' v `[. d � O W
6.Is(are)the well(s)plermanent or OTemporary Signature of 06tified Well Con ctor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or No with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information I nd explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under 421 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: OILP A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiereni(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: l3/ (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
above, also submit one copy of this form within 30 days of completion of well
�U� ` ��
(i.e.auger,rotary,cable,direct push,etc.) 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: U 1 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 Amount: completion of well construction fto the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016