GW1-2021-00458_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information•
/►,� Q �/ f/LN I�l� 14.WATER ZONES
Well Contractor Arne FROM To DESCRIPTION
ft. ft.
3/70�9 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR LiNER if a Iicable
��S �• FROM TO DIAMETER THICKNESS MATERIAL
fff��A ft. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. fr. in.
Water Supply Well: 17.SCREEN
FROM To DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural DMu 'pal/Public tr. fr. in:
1 Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft
Industrial/Commercial Residential Water Supply(shared) 10.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
:]Monitoring EIRecovery
Injection Well:
Aquifer Recharge Groundwater Remediation ft.
19.SAND/GRAVEL
GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stonnwater Drainage
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soillrock e, rain si x,etc.)
Geothermal(Heating/Cooling Return) _�Other(explain under#21 Remarks) fr. ft.
4.Date Well(s)Completed:/0"27'W Well ID# ft, ft. ll
5a.Well Location
y:�
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
3G3�1 5IbllIt F a.."d�/. ldw/. ft. Ni_
Physical Address,City,an Zip Z'z/7
21.REMARKS
County Parcel identification No.(PiN) 1-e
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3G°//• /39 N 79° Z/. yy7 t W
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Co a or Date
_
By signing this form,1 herebv certify that the well(s) was(were)constructed in accordance
7.is this a repair to an existing well: 0<s or [3No with 15,4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis is a repair,fill out known well construction infornmtion and explain the nature afthe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this forms.
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 Ito provide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
L�
9.Total well depth below land surface: /20 A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiiferent("example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: ta (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use'•+-_ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (Q (in.) 24b. For Infection Wells: In addition to sending the forum 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 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 24c.For Water Supply&Infection Wells: In addition to sending the form to
ttJJ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount:_7/O Z• completion of well construction to',the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016