GW1-2021-00329_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Nell Contractor Information:
LarN ,1 V, brA Y 14.WATER ZONES
FROM TO DESCRIPTION
Well Contract Nam�e�z 2 'n
�� ft. � ft. 1 ' i 'l
✓✓ft. ft.
NC Well Contractor Certification Number _ IS.OUTER CASING for multi-cased wells'OR LINER if a licable
��.�' 1 ^1��' rl N L FROM ft TO ft DIAMETER n THICKNESS MATERIAL
Company Name \ 1V1 v ` 1� 3-3 P VC,
16.INNER CASING OR TUBING ebtlicrntal closed-loop)
2.Well Construction Permit#: FROM TO I 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. ft. in•
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_;Agricultural [DMunicipal/Public 33ft. 43 ft. in. (Lasch
:]Geothermal(Heating/Cooling Supply) fResidential
Water Supply(single) ft. ft. in.
= Industrial/Commercial Residential Water Supply(shared) 18.GROUT:
_ hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. e 1 ft. 1O _
Monitoring Recovery
Injection Well:
_ Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if A licable
Aquifer Storage and Recovery rIISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:Aquifer Test OStormwater Drainage ft. ft. # ux
_i Experimental Technology []I Subsidence Control
Geothermal(Closed Loop) r.1ITracer 20.DRILLING LOG(attach additional sheets if necessary)'
In
Geothermal
TO DESCRIPTION color,hardness,soil/rock type, rain size,eta)
Geothermal(Heating/Cooling Return) IOther(explain under#21 Remarks)
4.Date Well(s)Completed: �-'o Well ID#
Sa.Well Location:
J ft. �C ft- A'O�r1
Facility/Owner Name ^� Facility ID#(if applicable)
lV" \ 5 _bVym YA
Phy at Address,City,and Zip
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwelll field,one lat/long is sufficient) 22.Certification: ; .; i'iii� f~ is,J(rI_tf➢ f d dial I
_. 5"' 1 g 3SC N -790 30, L3---t> W Ili a�
6.Is(are)the well(s) ermanent or 1ITemporary Signature of C ified Well Con ctoi Date
R ���,, y111 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 o with ISA 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 a`d explain the nature of the copy of this 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 iwell 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: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii fereni(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.) 24b.For Infection 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: �Utd �� 11 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) 1 O Method of test: OY1f1 ��� 24c.For Water Supply&iniection Wells: In addition to sending the form to
the address(es) above, also I submit one copy of this form within 30 days of
13b.Disinfection type: Amount: (�2+ G(�t completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016