GW1-2021-00370_Well Construction - GW1_20211220

WELL CUNSTRUCTRIN RECORD ((_4W-1) For Internal Use Only:
1.Well !Contractor Information:
�— T
,y �1�1 1`l t� " � 14.WATER ZONES
Well Contractor�Nanm a FROM' TO DESCRIPTION
l3 Vr� �`1 ft. ;'y fL 1
ft. V ft.
NC Well Contractor Certification Number is.OUTER CASING(for multi-cased wells OR LINER(if a Ucable)
WIrs (n l 0(1 n,l l �� FROM TO DIAMETER TffiCKNff MATERIAL
Company Name U, U V l` \/( 1 \ tt �(� tt 0 in. ,3`b�
16.INNER CASINGIOR TUBING' eotbcrmal closed-l000l
2.Well Construction Permit#: 5� FROM To DIAMETER TffiClagEss I MATERIAL
List all applicable well consnvction permits(i.e. VIC,County.State, Variance,etc.) ft. ft in.
3.Well Use(check well use): . ft. ft. in.
Water Supply Well: L 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICIG\ESS MATERIAL
_ Agricultural O.Municipal/Public I ft Cp a in. `� a, &A-)V C) P v C-
Geothermal(Heating/Cooling Supply) residential Water Supply(single) �L ft. Jft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
hri ation FROM TO MATERLA.L I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. o , 3'�2
Monitoring DRecovery ft. ft. OV�Y
Injection Well:
Aquifer Recharge Groundwater Remediation ft. ft
19.SAND/GRAVEL PACK(if a licable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage 'd I ft. 110 ft-
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) MTracer 20.DRILLING LOG(attach additional sheets if necess )
Geothermal(Heating/Cooling Retum) MIOther(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rack in si etc
D ft ft
4.Date Well(s)Completed: 3 'al Well 11D# 1 IL ft
5'a.Well Location: ` CZ ft ft. C,
` CKQ S.7 t��1 1 C 62, 1 P. 'a Q ft ft A-ao a.
Facility/Ow erN'am11e ( Facility IDr(ifappbrabie) a) } ft. ft
Ib-� 1-7 ft. Q ft
Physical Address,City,and Zip ri n5b u fZr N L a$]jcj�- ft. ft
�(1Q•�1�� J 21.REMARK.S 1
County Parcel Identification No.(PIN) EC 2 0 2021
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lar/long is sufficient)
22.Certification: a
i 'r b
6.Is(are)the well(s)MPermanent or QiTemporary Signature o ertified well C tractor 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: []Yes or No with 15A NCAC 02C.0100 or 15-?NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copv of this 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:
r� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: `O (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Ca,200'and 2Q1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above caring,use"+•• I617 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:t t��
tnn D�r'-r�,tx above, also submit one copy of this form within 30 days of completion of well(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) y Method of test: j 24c.For Water Suoniv&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: M \ Amount: 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