GW1-2021-00366_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
�Y ►V1 1``1 14.WATER ZONES
Well Colntractor Name FROM TO DESCRIPTION
t. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER(if a ticable
FROM % DIAMETER THICKNESS MATERIAL
ft. �. ft. in. go I Pv�
Company Name
16.1NNER CASING OR T BING16othermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ak_ AgriculturalMunicipaUPublic t, of ft, in. O QVC,
_;Geothermal(Heating/Cooling Supply) fflResidential
esidential Water Supply(single) ft. ft. in.
Industrial/Commercial Water Supply(shared) 18.GROUT.
Irrigation FROM TO MATERIAL EMPLACEMENT METHO &AMOUNT
Non-Water Supply Well: ft. �7F1 ft. te1 nm,,,
Monitoring ORecovery Sa/L
Injection Well: u
ft. ft.
__Aquifer Recharge Groundwater Remediation
_'
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery ISalinity Bonier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ON ft. ft. �A
Experimental Technology 0ISubsidence Control ft. ft.
Geothermal(Closed Loop) r.IITracer 20.DRILLING LOG(attach additibnat sheeti if necessa`
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc)
_i Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) ft.
4.Date Well(s)Completed: I I _a V Well ID#
ft. P ft. 1�7
a.Well Location: oc '�L
I
ft. ft. yowe
Facility/O er Name Facility ID#(if applicable ft. ft.V) �y
Physical AddrIss,City,and Zip �V` p — ft. ft.
b~ °
V 1 6 )1 s UI I 30 1 l 21.REMARKS I
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
'' 2 I 22.Certification:
135 1 1D33-4 M�Q 0 N 10 + UJUo-7U Wn—x/
6.Is(are)the well(s) Permanent or [(Temporary Signature of C4Vfied Well Contra or 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: EIYes 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 all"plain 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: v�j SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 199 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3 00'and 2@100') construction to the following:
10.Static water level below top of casing: _ 1-7 (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 Injection Wells: In addition to sending the form to the address in 24a
D above, also submit one copy of this form within 30 days of completion of well
12.Well construction method:��� AaVA-1 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,JUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: u 1 I I �l 24c.For Water Supply&Iniectiion Wells: In addition to sending the form to
f the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: d 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 Resource Revised 2-22-2016