GW1-2021-00335_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
't ` 14 �W 14.WATER ZONES.
Well Contractor Name FROM TO DESCRIPTION
g 3
u�Y!/✓� ft. ft. R
NC Well Con ac r Certification Number
`4,� `� p 1 `I 15.OUTER CASING for multi-cased wells 0 t LINER if a licable
1. 1 l ( 'R FROM TO DIAMETER THICKNESS MATERIAL
_1 ft. -1 � r 1 0
Company Name 1 J `I
11� 16.INNER CASING OR TUBING' t:olhcrm al closed-too
2.Well Construction Permit#: d 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
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural icipal/Public ft. n 2ft. in. l0` �hr 1 v pv C
bb�7 i -1
j Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. i❑•
_:
_ Industrial/Commercial DResidential Water Supply(shared) 18:GROUT:
_ hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. a fl ft. ,y��; Z�Zr�p bS e�c11•
Monitoring DRecovery
Injection Well:
ft. ft. ,
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable
Aquifer Storage and RecoveryISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStonnwater Drainage ft. 7�ft. .� Door
Experimental TechnologyISubsidence Control ft. ft.
_.;Geothermal(Closed Loop) (Tracer 20.DRILLING LOC(attach'additionil`sheets if necessa '
J Geothermal(Heating/Cooling Return) 01Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc.)ft. ft.
1 i S•O`
4.Date Well(s)Completed: of 1 b Well ID# ft*
ft.
ft. ft.
Sa.Well Location:`�' C
�� & Y V,,VU-1 3 ft. ft.
Wai
Facility/Owner Name Q y�F�aciili y IDS#(if applicable) ', ft. �?� ft.
Physical Address,City,and Zip
V%zi �VD`1 \A 21.REMARKS
County Parcel Identification No.(PIN)
IV
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
if well field,one lat/long is sufficient I `
( ) 22.Certification:
4 OOy N lac)c) a t -o A W ( t
6.Is(are)the wells) ermanent or OTemporary Signature of Ce 'ied Well Co❑trac r. 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 ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
ffthis is a repair,fill out known well construction information 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: �j SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(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: (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: n.� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,1Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 17 Method of test: v 1 24c.For Water Supply&Iniection Wells: In addition to sending the form to
t 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016