GW1-2021-00357_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor`Information: '"�✓
14.WATER ZONES
FROM TO DESCRIPTION
Well Contra��M[[or`N/ame�� 01 ft. ft SA
n
if
ft. fL
NC Well Contractor Certifi ation Number
( � 15.OUTER CASING(for multi-cased wells)OR LINER(if a liable
FROM TO DIAMETER THICKNESS MATERIAL
11 IIJJ J l ` \ fL q ft. in. `}('� p VC,
Name i I -ah 16.INNER CASING OR TUBING eotherntal closed-toot"
2.Well Construction Permit#: W C- Qo (y)"D '7� FROM To I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. VIC,County,State, Variance,etc.) ft. fL in.
3.Well Use(check well use): . ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_ Agricultural DMunicipal/Public ft. 5 3fL a in.
:)Geothermal(Heating/Cooling Supply) residential Water Supply(single) f. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft• 02� ft IDnt 31/2
Monitoring DRecovery fL ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if ap I plicable)
_ Aquifer Storage and Recovery QlSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage .1�0 fL 5 a>".
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) rJITracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) M10ther(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
4.Date Well(s)Completed: _ �C oZ Well ID# a ft. fL
5a.`Well Location: / ft. ft. �� t✓/a`
Facility/Owner Name FacilityIDn(ifappplicable) I f. C G A
f. ft._51 )-A SqAd
Physical Address,City,and Zip ` fL fL
1 O IOU �-1I p� �� 21.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: O
Signature of ied Well Co ctor ' �''i)at� r,
LIM, wag,
6.Is(are)the well(s);Permanent or Temporary 7 yt lY,.:...
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: JoYes orJ�fyo with 15A NCAC 03C.0100 or 15.4 NCAC 01C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL IlVSTRUCTIONS
9.Total well depth below land surface: 53 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferew(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,
(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
12.Well construction method: MU.6 \VJ above, also submit one copy of:this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) U
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: 00 'o I C-q 24c. For Water SUDDIV&Iniection Wells: In addition to sending the form to
` , i I the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: I'\ Amount: `C completion of well construction E 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