GW1-2021-00711_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
A\ -N V y/ 14.WATER ZONES
Well C ntractor Name FROM TO DESCRIPTION
ft. CA to
NC Well Contractor Certification Number
15.OUTER CASING for'mulli-cased wells OR LINER if a ' licablc
r,N`D 1 h`\1 FROM TO DIAMETER THICKNESS MATERIAL
f` V` \ ,` , ft. a(Q ft. in. I SCIl-040 P\,-
Company Name
0 1 16.INNER CASING OR TUBING `eothcrmal closed-too
2.Well Construction Permit#: 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 E3Municipal/Public ft. ?, tt. in.
gw `1
'Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. fin•
Industrial/Commercial Residential Water Supply(shared) 18 GROUT'
_ - ItTi ation FROM TO MATERIAL EMPLACEMENT METH D&AMOUNT
Non-Water Supply Well: _\_
__'Monitoring Recovery ft. ft. V
Injection Well:
_ Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(If applicable),
_,'Aquifer Storage and Recovery DISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test r.1IStonnwater Drainage 'd' 0 fL - ft. S� ur
I_ Experimental Technology 0ISubsidence Control ft. ✓v tt.
Geothermal(Closed Loop) ITracer 20.DRILLING LOG(attach additional sheets if necessa`)'
FROM TO DESCRIPTION(color,hardness,soil/rock ty e, rain size,etc.)
__I Geothermal(Heating/Cooling Return) I IOther(explain under#21 Remarks) D ft. � ft. t71
4.Date Well(s)Completed: I I_0 —0 Well ID# A
ft. ft. -N
ft. ft.
5a.Well Location: voul CA
Facility/Owner Name In�'` 1vUy1r� p Facility ID#^(iifaapplicabl`e)�/ aU ft. 7� ft. }al-
��C LUD SW Lk ttY_ 1 oo �1 go IK.�✓ ft. 7 fL
Physical Address,City,and Ap
e 1 `nn rn e 0 h fy j - 21.REMARKS DEC 08 County um be N 1` Parcel Identificattiion No.(PIINI) 0�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/lo sufficient)
ng is sucient) 22.Certification:
35 ,
lr•_
5 t 0(,Pq''04 N : �\U q XQ� W
6.Is(are)the well(s) ermanent or [ITemporary Signature of rtified Well ntractor Date
777 """ 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: nIYes or Wo 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 informationabd 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: 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@200'and 2@100') construction to the following:
10.Static water level below top of casing: �3 (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
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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: numc)IrA 24c.For Water Supply&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: 11 completion of well construction to the county health department of the county
where constructed.
f
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016