GW1-2021-00706_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
tat RA �1\`�C&J 14.WATER ZONES i
FROM TO DESCRIPTION
Well ContractorQNam ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a licable
1XIII FROM TO DIAMETER THICKNESS MATERIAL
` ft. ft. in. �
R
Company Name
^ � ' 16.INNER CASING O TUBING cotherntaI closed-loo
2.Well Construction Permit#: �`�(1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. VIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. it. in.
17.
Water Supply Well: FROM SCREEN,TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Aglicultural OMunicipal/Public ft. ft. ln• O a D
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial FResidential Water Supply(shared) 18.GROUT
Irrigation a ZtFD TO MATERIAL l EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
_ Aquifer Recharge n Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery nISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStonnwater Drainage
Experimental Technology []ISubsidence Control
Geothermal(Closed Loop) MITracer 20.DRILLING:LOG(attach additional sheed if neccssl4
EGeothermal(Heating/Cooling Return) 01 (explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc.)
ft. a ft.
4.Date Well(s)Completed: oC� Well ID# ft. ID,
ft. r; u
5a.Well Location: ft. a�R ft. --7V30 n mvit J
ChIm � ft. ft. +0Lh S
>ci�MOwner Name (`�) Facility ID#(if applicajblle) OC ft. ft. b�a/)Of c Q
� J 1 1 U& n� .Y t tvrxrn�— l.`
PbysicaI Address,City,and Zip ft. ft. DEC
mos (� �� 21.REMARKS
Coun y arcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
34° J
J N t 1pq3 W w ` a
6.Is(are)the well(s)y/I Permanent or OTemporary Si�gnalure of Cer' d Well Contract - Date
/'^ By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [IYes or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information *dexplain 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: 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 if different(example-333@200'and 2@100') construction to the following:
10.Static water level below top of casing: a (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 Iniection Wells: In addition to sending the form to the address in 24a
-II above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: Y�(�U GU-0 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
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 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