GW1-2021-00707_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Informatiot
LizW��� I _ �7r. 14.WATER ZONES.
Well Contractor Na a FROM TO DESCRIPTION
a ft. 3a ft.
ft. ft.
C Well Contr ctor Certif cation Number
�•�I' J V�l!` ��I�� 15.OUTER CASING yor'mutIi-cased wells OR LINER if a`'licable
k FROM TO DIAMETER THICKNESS MATERIAL
QliV
Company Name I _
1�01�- 16.INNER CASING OR TUBING 'c`olhermal closed-loo
2.Well Construction Permit#: d 34
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. VIC,County,State, Variance,etc.) ft. fL in.
3.Well Use(check well use): ft. ft. in.
11 SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public �ft. ft. in. O1a +C) Yc,
Geothermal(Heating/Cooling Supply) EResidential
esidential Water Supply(single) ft. ft. in.
Industrial/Commercial Water Supply(shared) 18:GROUT,
1n1 ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, Y-
_ Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
' Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if a licablc
Aquifer Storage and Recovery ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:)Aquifer Test OStonnwater Drainage R0ft. `3a0. -Wa Sam
Experimental Technology r.1ISubsidence Control ft. ft.
B
Geothermal(Closed Loop) MITracer 20.DRILLING'LOG(attacGadditioaalshectiifaecessaFROM TO DESCRIPTION(color hardness,soil/rock ty e, rain size,etc.)
Geothermal(Heating/Cooling Return) IOther(explain under#21 Remarks) ft. 'k ft. i 1
4.Date Well(s)Completed: Well ID# ft. ft.
5a. ell Location: n ft. 1 ft, h 1J
ft. ft. � k i�. 'lam
Facility/Own -Name Facility ID#(if applicable)Q D_ ft. ft se
/J "`.�,p
t a3o ft. ft. ,`
Ph ical Address,City,and . k I ft. ft.
1J1/I UlA 5 -A-0-0 e 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) r-� O 22.Certification'
6.Is(are)the well(s)Permanent or EITemporary Signature of rtified Well ntractor Date
777TT�" By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: EIYes 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 a d explain the nature of the copy of this record has been provided to the well owner.
repair under 421 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 I 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: 3� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@20000'and 2@I00') construction to the following:
10.Static water level below top of casing: 1 (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
1 above, also submit one copy of this form within 30 days of completion of well
12.Well construction method:1(Y1 Ud 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) `0 Method of test: 1 24c. For Water Suanly&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: 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