GW1-2021-00701_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Inforrmatiioon`: ,l
Lrr•� �✓►f` ,I T Vy"t J�' 14.WATER ZONES
Well Contractor 14ame FROM TO DESCRIPTION
Q t03_4 �ft. it Gr ft. q h set Ind d- rot ve
ft. d r tt. �
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER(if a Ii abie
r FROM TO DIAMETER THICKNESS( MATERIAL/✓� If V S tie k ✓,I 1 I t� '+'t ft. ,2 s ft. a in. ,5CHgV PYCi
Company Name
16.1NNER CASING OR TUBING cothcrmol closed-loop)
2.Well Construction Permit#: 0 J Q / / O FROM TO I 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.
17.SCREEN: r
Water Supply Well: `
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_i Agricultural Municipal/Public 95 it. a in. .SL.Hq V PVG
__I Geothermal(Heating/Cooling Supply) sidential Water Supply(single) it ft. in.
__ Industrial/Commercial Ptsidential Water Supply(shared) 18.GROUT.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (9 ft. ft. f)1 t11 (!U r - O ec 'S
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
_ 7
Aquifer Recharge m Groundwater Reediation
19.SAND/GRAVEL PACK If appiicablc '
_, Aquifer Storage and Recovery rIISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
__,Aquifer Test
IStonnwater Drainage 2 p ft. tT %ft. Sun Vt,IY jv1 T
J Experimental Technology (Subsidence Control
Geothermal(Closed Loop) ]Tracer 20.DRILLING LOG(attach'additional sheets if necessa
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
__�Geothermal(Heating/Cooling Return) _'�(Other(explain under#21 Remarks) O ft. ft.
O S8 .
4.Date Well(s)Completed: ^� '2V2�ell 1D# ft. ft. / t d i s G 1 A -Sit M 1'X
5a.Well Location: /' I ft. ft. �Yan t_c✓ht 4 G/G
samor Cree/C Land U- l fc. ,2S tc. ri _c/ay
Facility/Owner Name Facility ID#(ifapplicable) ft. n ft' ve
�5S6 tSwee f -Cuu►- S-Wma n tvC zbl 3 1(> ft. ft.
Physical Address,City,and Zi ft. ft.
Gu rt 17e��a n� 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: p E C o 2021
(ifwell field,one lat/long is sufficient) 22.Certification:
17
J,2a2
tN (ia
6.Is(are)the well(s) ermanent or OTemporary Signature of Cer red Well Contr for Date
YYY�����` 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: OYes or o with ISA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information nd explain 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: q SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@2000'aand 2@100D construction to the following:
10.Static water level below top of casing: O (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 Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: d
��� above, also submit one copy of ,this form within 30 days of completion of well
U ry 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
E
13a.Yield(gpm) Method of test: /l 24c.For Water Suanly 8t Infection Wells: In addition to sending the form to
1 the address(es) above, also subrihit one copy of this form within 30 days of
13b.Disinfection type: Ttf Amount: CiA 9 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