GW1-2021-00331_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
t.
14,WATER ZONES
FROM TO DESCRIPTION
Well CDntractorNae rl I 1 ft �'1 1 ft. a
a&2> `i ft. l`-C ft.
NC Well Con for Certification Number i , 15.OUTER CASING for multi cased`,wells ORLINER if a licable
1 1 `� OM TO DIAMETER THICKNESS MATERIAL
f[. �Q ft. in. (1
Company Name C� Y
NNER CASING OR TUBING eothernial closed-loop)
2.Well Construction Permit#: I J�`1 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. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:.,)Agricultural [nMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 9911kesidential Water Supply(single) ft. ft. in.
__ Industrial/Commercial Residential Water Supply(shared) 18,GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ECG ft. 3C nt V►l I
_ Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
- Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if a _lkable
Aquifer Storage and Recovery [MISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_.Aquifer Test D S[onnwater Drainage
ft. ft.
_]Experimental Technology r-1ISubsidence Control ft. ft.
Geothermal(Closed Loop) rJITracer 20.DRILLING LOG(attach additional sheets if necessa
BGeothermal(Heating/Cooling Return) I(Other(ex lain under#21 Remarks) FROM ft. TO ft.
DESCRIPTION(color,hardness,soil/rock type, rain size,etc.)
b o�1
4.Date Well(s)Completed: a 3 Well ID# ` ft.ft. ft.q` ft. AU C la
,� e
Sa.Well Location:
Q
Facility/Owner Name Facility IDll#(if applicable) ft.
1 ft.
(J
Physical Address,City,and Zip ft. ft.
�hns�on 21.REMARKS + I "
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: O�'
(if well field,one Iat/long is csufficient) q � 22.Certification'
N 0� R^I, .3w W Jov
W�U` n
6.Is(are)the well(s) permanent or OTemporary Signature of Cer ed Well Conloctor I I 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: OYes or No with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction informationJndexplain 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: Q C� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: l7_J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdperew(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: 10 (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
Nan
12.Well construction method: 1�v � Cy (1'1 "��<iY 4 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLYY WELLS ONLY: d� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) � Method of test: Vm Y 24c. For Water Supply&Inij ction 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 to the county health department of the county
where constructed.
Form GW-1 Notch Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016