GW1-2021-00337_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Info`rmattion:
Ur U v` 14.WATER ZONES i
Well Contractor Name FROM TO DESCRIPTION
C Well Contractor Certification Number 15.OUTER CASING for muT-casediwcits OR LINER if a licable
.l FROM TO DIAMETER THICKNESS MATERIAL
Company Name ` ft- Tj'I ft- in. SL)li t4 o
16.INNER CASING OR TUBING ebthermal closed-loo r V
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List allapplicable 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 OMunicipal/Public S:1 tt. ft. in 1h"1 o
Geothermal(Heating/Cooling Supply) tResidential
esidential Water Supply(single) tt. ft. fin•
Industrial/Commercial Water Supply(shared) 18.GROUT'
fiTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring ORecovery
Injection Well:
ft. ft.
Aquifer Recharge El Groundwater Remediation 19•SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStonnwater Drainage Oft ( ,a ft.
Experimental Technology 0ISubsidence Control ft. ft.
Geothermal(Closed Loop) r.JITracer 20.DRILLING LOG(attach additional sheets if nece'ssar `
__I Geothermal(Heating/Cooling Return) ]Other(explain under#21 Remarks)
ks) ft. TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc)
ft. '
4.Date Well(s)Completed: Well ID# ft. ft.
Sa.+Well Location: e ft. \Q
N \'at(� �V�IAI��� a fL J-1 f. c L'-1
Facility/Own//e��rName r Facility ID#(ifapplicable) 5-1 01 sa
Physical Adpdr�esjs�,yC�ity,and Zip � Q (�
" "�"� b�—M 1 21.REMARK
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one
lat/lloon'g^is sufficient) Q 22.Certification:
W , / 'T S_
6.Is(are)the well(s)0Permanent or OTemporary Signature ofCcroed Well Contra or Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information a d explain the nature ofthe copy ofthis retard has been provided to the well owner.
repair under#21 remarks section or on the back ofthis.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: Log A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi[ferent(example-3@20000'and 2@100') construction to the following:
10.Static water level below top of casing: y (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: rn 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) (� Method of test: m ( 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: Yt 10 Amount:_3 o Z 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