GW1-2021-00708_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:1
j
W`r n 1'`l� I r 14.WATER ZONES
Well Contractor Name J
4n FROM TO DESCRIPTION
O Llt3 17 3 ft. 4 1 ft. r` ,,
CPNC Well Contractor Certification Number 11 1 ft 5 3 ft �- `/�f rt�L 5^Gt n
15.OUTER CASING(for multi-eased wells)OR LINER(if a li a
t-6 Yd1 ]- C (VOA
t 1 1�` FROM TO DIAMETER THICKNESS MATERIAL
U y V ` "` t l It. ft. in.
Company Name `1
/���� c) 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 2oZ` Ooo FROM TO 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public '3`1 ft. T1 ft. oZ in. 0\ Sctyg1) P\(L,
❑Geothermal(Heating/Cooling Supply) Cwsidential Water Supply(single) Ln 1 ft. 5 t• a in. p vc
❑Industrial/Commercial //❑Residential Water Supply(shared) 18.GROUT 1'
❑Irri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: et. ® ft. i�flltifl�
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage IX et. S ft. 1L 2-❑Experimental Technology ❑Subsidence Control ft. ft. tl
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ft. /� ft. S
4.Date Weil(s)Completed: g has Ia I Well ID# ft. r I ft. pV e- un clew
5a.Well \^t /� �( ft. ft. a U
urA
Facility/Owner Name Facility ID#(if applicable) 141
ft. l ft. P fj 1`s h C r u
o M1 IIS ,NL aj ft. S3 ft. red r d is h ;t{'L
Physical Address,City,and Zip -
��1__✓��� ,t� 21.REMARKS
County C�1 Parcel Identification No.(PIN) 8
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: , t
l� ,!2�lggStb. N ` fig t 01H 1q3_�L W A��
6.Is(are)the well(s): L ermanent or ❑Temporary Signature ofC ified Well Cofactor Date
1 ` By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Ell es or 0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a coPy
If this is a repair,fill out known well construction information and explain the nature of the 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 construction info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 t@200'and 2@100')
qC I (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
24b.For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: t(YWL1� �Ov�n 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018