GW1-2021-00412_Well Construction - GW1_20211206

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Infor ation:
t - ) ok'r h r✓-*-- 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. fL
�Wefiontractor Certification Number �r 15.OUTER CASING for mule-cased wells OR LINER f a lieable .
G {lyo FROM TO DIAME R T�CKNESS MATERIAL
Company
\ ft. �p ft. 6 1¢m. spa-at 1'v c—
Company Name
I16:INNER CASING OR 1'[JBI4G eothermslklosed-loo z: >. .
2.Well Construction Permit#• &0 r C 4 4 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. fL in.
3.Well Use(check well use): ft. fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SUE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) ORcsidential Water Supply(single) ft. ft, in.
Industrial/Commercial 13Residential Water Supply(shared)
18.'GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: +u fL 94 fL nC( SOD �j ch`ZD
Monitoring Recovery ft. fL Mt
Injection Well: _ ft. ft.
Aquifer Recharge y Groundwater Remediation
19 5AND/GRAVEUTACK!if f"licatile
Aquifer Storage and Recovery 13Salinity Battier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20 DRILLING LOG ch-dditioniil sheets if.necessary)
Geothermal(Heatin Coolin Return) 6 Other(explain under#21 Remarks) FROM TO DESCRIPTION color hardn sail/rack in s' etc
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4.Date Well(s)Completed: 1 Well ID# 6 ft. v� O ft- G e^���
5a.Well Location: 4o ft. El t 0,i
Facility/Owner Name Facili (if applicable) ft
ft. fL
P ieal Address,City,and Zip a ft. ft
13 0500W OD 21.REMARKS
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County Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C rtification:
ECA�� i
6.Is(are)the well(s)airermanent or Temporary Signature of Certified Well Contractor 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: 13Yes or 1Vo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a -
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis 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 o wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: s o 5 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d/jjerent(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing: 4 (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+" l0 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: d*G' r-`M construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: �r 24c.For Water Supply&Iniection 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: l Amount. ) O 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