GW1-2021-00546_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: 1 az-ej
14:WATER ZONES'
FROM TO DESCRIPTION
Well Contractor Name 1^
3
NC Well Contractor Certification Number �►^�
15.OUTER CASING for mulfi-cased?wetls 4R LINER if a licable
R`1 �� FROM TO DIAMETER THICKNESS MATERIAL
Company Name 46.INNER CASING OR TUBING eothermal'closed-loop
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pernhiis(i.e.UIC.C'nuniy,Slate.Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in•
Water Supply Well: 17,SCREEN
PPY FROM TO DIAMETEW SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) IffResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 75.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft, -,V—
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
i9.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) `'Y ft. is ft. ?"a .
4.Date Well(s)Completed: 6 1 - Well ID# l ". 3 ft, T-�- Spx L
5a.Well Location: 15)--ft. Cj_( ft. -� �
15-6 ft. /�7.1-J7ft. LM6r5-:1CO
Facility/Owner Name 1 _ Facility ID#(if applicable) ft. ft.
(D ItilV�o L�• Y{O' l ft. Cl 7 ft.
Physical Address,City,and Zip ft. ft. 2 2021
D ► �C��C t 21.REMARKS.`
County ( Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IatAong is sufficient) 22.Cer ilieation:
N W & r
,, , ';�� I/-17. ;LA
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Contractor Date
By signing this limn• 1 hereby c•erlyjp dial the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Consinuction Standards and that a
tf 1hi,s is a repair.,lill mu known well construction inlonnation and explain the nature a/'the crept,of this record has been provided to;the well owner.
repair under N21 remarks section or on the hack of this/iron.
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 I GW-I 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: `14� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
b'or•nniltiple wells li.vi all depths if di(feh•ent(exanhple-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,
lfwater level is above casing,use/f' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: V (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
n �r n r� above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: f T I� 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
r
13a.Yield(gpm) �� Method of test: IJ1� 24c. For Water Supply& Infection Wells: In addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: Amount: W completion of well construction to the county health department of the county
where constructed. F
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016