GW1-2021-00340_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
TY14.WATER ZONES
PTION
Well Contractor Name FROM TO DESCRI
/� U,
Zia I Pr
NC Well Contra;ZtCon Number 15.OUTER CASING(for multl•cased wells)OR LINER(if a ►icable)
`I 4_ �' I i/� FROM TO DIAMETER THICKNESS MATERIAL
y V 1 E S 4 1 1 ` -1--I ft. ft. I �p in. I qn VC,Company Name
1 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Count),,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FROME TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ��idcintial
pa/.Public Ut. ce ft. a in. 1 a � q�
❑Geothermal(Heating/Cooling Supply) Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri ation ❑Wells> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage OOo ft. Lol
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return)
TO DESCRIPTION(color,hardness,soiVrock type, in size,etc.)) ❑Other(explain under#21 Remarks) Q ft. ft. �a(,(
4.Date Well(s)Completed: Z- Well ID# / ft. F ft• r(�I�y"� SNTt Ock
5a.Well Location: T ft. /!F ft. Oycw
I
- V hU �u�+ 1 O ft. j
�/1
Facility/(Owen Name Facility ID#(ifapplicable) oft. 6 / ft. �� r1,
2- l.Y �W l&l S Ln 1�/1ay-b r�y) 1 ' N3&
Physical Address,City,and Zip ft. ft. oFc 2 0 2021
go� M R_3pq _ 05'(�Iq_3 21.REMARKS
County Parcel Identification No.(PIN) I' «'y t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i'.,
(if
�well
Lfield,
-one]at/long is sufficient) 22.Certification:
Ib 1 N / 1 3�Z:08
Lei W gCA� W.,� � 4 W 21
6.Is(are)the well(s): rmaaent or ❑Temporary Signature ofCerbtied Well Conifictor Date
By signing this form,I hereby certift,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/f this is a repair,fill out known well construction information and explain the nature of the 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 construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: ++ ,^ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: l Y (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
I (ft.) 24a. For All Wells: Original (form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (in,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: i/rl/ Y 24c.For Water Supply and Op n-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018