GW1-2021-00341_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: \/
r 14.WATER ZONES.
Well Contractor Nalne FROM TO DESCRIPTION
aft. ft. r
ft. tt.
NC Well Contractor Certification Number 15.OUTER CASING for multi=cased iwll(s OR LINER if a licable
`h'�; r L p I 1 f`�`` FROM TO DIAMETER THICKNESS MATERIAL
Company Name l
16.INNER CASING OR TUBING e6thernial closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. VIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.FROMREEKf0 DIAMETER SLOT SIZE THICKNESS MATERIAL
:,)Agricultural E3Municipal/Public ft. O�t• in. SUNIAO�1a vG
_I Geothermal g Supply) FIResidentialeatin /Coolin Su 1 esidential Water Supply(sin le) 18.GROUT: in_ Industrial/Cmmercal Water Supply(single)
ft ft ,
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring DRecovery
Injection Well:
_ Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL PACK if a' licablc
Aquifer Storage and Recovery rJISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IStonnwater Drainage at) fur
:)Experimental Technology QlSubsidence Control
BGeothermal
Geothermal(Closed Loop) naracer 20.DRILLING LOG(attach additlorial sheets if necessar(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)(Other(explain under#21 Remarks) try ft. rl ft. � �t
4.Date Well(s)Completed: �0�;;kb Well ID# `, ft. �S ft.
Sa.Well Location: i , ft. ft.
C
YWn � j`l as f. Q
Facility/Owner Name Facility lD#(ifapplicable) Q ". 4Tau s cnj
��&t Sy VW ) a 6`11
Physical Address,City,and Zip G I� 1a ft.
R� -/ o�r • o a —�oJ, 606 .REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
3�1° 50, 1ga, N 03 ,(A0 w IAM,n /��J °►� ID�ao
6.Is(are)the well(s)"`iit���Permanent or OTemporary Signature of Ce red Well Con for' a ( 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: rJYes or No with ISA NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction it formation nd explain 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-I 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: �d (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if ddereni(example-3@200'and 2@I00� 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 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: %3A Rt1 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 m i(gp ) �� Method of test: �) 24c.For Water Supply&Infection Wells: In addition to sending the form to
' 1 f the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: t-f completion of well construction to the county health department of the county
M.—constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016