GW1-2021-00365_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: �l
` 1 ` - V 1 I/I 14.WATER ZONES
Well Contractor Name FROM I TO DESCRIPTION
t. 3 ZJ'fr h G�1�41�CG
ft ft.
NC Well Contractor Certification Number
n ' \ is.OUTER CASING for mull-cased wells OR LINER(if applicablel
`t �� FROM TO DIAMETER THICKNESS MATERIAL
VVa l 1 F. +1 fL fL in. l 0 o�
Company Name
` 1 16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: (l�" ll� .�. FROM To DIAMETER THICKNEss MATERIAL
List all applicable well construction permits(f.e. VIC,Count),,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): . ft ft. in.
Water Supply Well: 17.SCREEN
FROM I TO DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
_ Agricultural OMunicipal/Public 3�t t in._ (Heating/Coolingft. 1 C'Geothermal SuPP1Y) Residential Water SuPP1Y
ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. &(D fL
Monitoring ORecovery ft. ft C Y
Injection Well:
ft. ft
Aquifer Recharge 10 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
_ Aquifer Storage and Recovery 0Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage a Oft I 3 ft �a, 5Ci f,
Experimental Technology OSubsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
_ Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)IOther(explain under#21 Remarks) /�ft 1 ft
lJ t�1
4.Date Well(s)Completed 3—3 O "�� Well ID# ft. fL Iced
Sa. Location:
ft. I''� ft V 1 Cl
1a•ra L� tc�n c� i — ft. ft.
Facility/Owner Name Facility IDr(if applicable) ft ft
�,4rr►C Ln U4 �O bUVU NL ft. ft ,� _V .
Physical Address,City,and Zip Ss�g� ft ft lk
r
.�JV-ny' `yr-, (9 011
)U5 3bJ 21.REMARKS �
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laat/long is sufficient) r t 22.Certification: "
da 3 a
6.Is(are)the we (s) Permanent or Temporary Signature of Ce d Well ContractV 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: [3Yes or �No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this 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 INSTRUCTIONS
9.Total well depth below land surface: 3S (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@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: (in.) 24b. For Iniection 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: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I Method of test: I rvA 24c.For Water SuDDIv&Iniection Wells: In addition to sending the form to
1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: /y (11�_ 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