GW1-2021-00347_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
VN \A' 1 'kD4 )� 14,WATER ZONES l�a
Well Contractor Name FROM TO I DESCRIPTION
a%ll�>1� a s ft cp C1 ft. ra em n
ft. ft i
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER(if a licable
`A� -s p FROM TO DIAMETER �c hyo MA
lio 11 ( ft ar�ft in.
Company Name
2.Well Construction Permit#: V�'� C 13p FR pvc—
OM
INNER CASING OR TUBING(geothermal closed-too
FROM TO DIAMETER I THICKNESS I MATERW,
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.SCREEN
FROM I TO DIAMETER SLOT SIZE THICICNF3S I MATERIAL
Agricultural MMunicipal/Public 25ft fL in. +CDIQ
pvc-
` Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft ft. in.
Industrial/Commercial OResidential Water Supply(shared) IS.GROUT
Ini ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. Q it.
Monitoring Recovery ft. ft.
Injection Well:
Aquifer Recharge Groundwater Remediation ft. ft
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery QlSalinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. #. ;� S _ 1 cx rlr
Experimental Technology DSubsidence Control ft. ft ���C7i
Geothermal(Closed Loop) EITracer 20.DRILLING LOG(attach additional sheets if necessary)
_ Geothermal(Heating/Cooling Return) TO DESCRIPTION(color,hardn soil/rock type,grain size,etc.) Other(explain under#21 Remarks) ,/� ft ft � SD ,
V /
4.Date Well(s)Completed: -a 3�a` Well ID# ft. ft
A -S A dV l►-t t
5a.Well Location: ft. J r� ft 4-G
(� ` ' ft. 6 ft e l n S Gt rl
Facility/Owner Name\ `1_ Facility
1 ID.#(if applicable) �ft. ft'
'u``/k ` J _5 U n M )'A'
r �T V�►`1'1�l�l\�� IG(JI 1\lI N 1 I� / 1 ft. Gl{, (!. a
Physical Address,City,and Zip 'Q' n'� �ft d�GI ft
C&-2f 1 a 5 i�a� qoa 2I.REMARKS /
b o0 J
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/lo(nng is sufficient) p� 22.Certil-teation
1� N ��O �� t��lJ W
4,pw,
6.Is(are)the wells) ermanent or OTemporary Signature of Ce6ged Well Contra or "" ate`
By signing this form,1 hereby certfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [)Yes or No with 15.4 NCAC 02C.0100 or 1 SA NCAC 01C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information nd 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 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: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd8erent(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: `-t' (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: NW& rvA
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 0 Method of test: l�PY,121 0cl 24c. For Water Supply&Injection 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: 1 l Amount: 1� completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016