GW1-2021-00345_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: �-
1.Well Contractor,Information: T,/
VtJ�.Y 1 v\ `N I L,t� y r 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ' w
�' �. 5-Ift. W- ft. ,Ux S(�
It. ft. kol
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a livable)
FROM I TO I DIAMETER 1 THICKNESS MATERIAL
}♦♦ ft. ,5✓) ft. in. C�,t Irmo pVc'
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 1n1 L d` FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Coun!x State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 5rJft. U*1 ft. Gti in. C,klgC. Vc-,
t
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. Ft. in.
❑Industrial/Commercial Residential Water Supply(shared) 18.GROUT
❑trri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. , ft. CQ l/a
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if appiivable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. i _� ft.
❑Experimental Technology ❑Subsidence Control ft. lF ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,sodfrock t e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) D ft. � ft. � ,�•�1�
4.Date Well(s)CompleteA�C)3 Well ID# Z ft. ft. a nA el
5a.Well Location:
ft. [ � ft. n C a
Facility/Owner Name Facility ID# if applicable) a ft. 5- 1- b l aClL C/a
3 h Mi s f7ft. 61' !?)Y&',q SA n
Physical Address,City,and Zipl
ft. ft. &If
r
d 21.REMARKS 57 'e
So
,�tn�ot✓ �ooab3�1
County Parcel Identification No.(PIN)
)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) Q 71 Q 22.Certification: ( 1° 'l
35 n Iq� N V t �V� O� W r 4" ti;,;ii,. . - A
6.Is(are)the well(s):*ermanent or ❑Temporary Signature of Ce 'red Well Con for Date
By signing this form,I hereby eertifi'that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If 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 1 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: �J/� (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifeti ferent(example-3@200'and 2@I00')
j� 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: v (ft.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter. (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: r '`M,UA lUb n y, 24c.For Water Supply and Open-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: Nrnon
13b.Disinfection type: "70Amount:
ILW
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018