GW1-2021-00719_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information; f
-LnMA1 1 1 (7 14,WATER ZONES v
Well Contractor Nam FROM TO DESCRIPTION
lft. ft.
NC Well ContraEtCrtif anon Number 15.OUTER CASING for multi-cased;wells OR LINER if a livable
FROM TO DIAMETER TffiCKNESS MATERIAL
1 � ft. ft. a in. S(.," �D
Company Name
�r1 _ 16.INNER CASING OR,TUBING eolhernial closed-loo
2.Well Construction Permit#: Ily1 L a 0 05—b O 3 17 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.
17.SCREEN .;.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_ Agricultural [DMunicipal/Public ''lft. ft. in. dl� \IL I
_;Geothermal(Heating/Cooling Supply) Wsidential Water Supply(single)
Industrial/CommercialIResidential Water Supply(shared) 18.GROUT
_; Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. Canft. ► 310
:-)Monitoring Recovery ft. ft `U
'
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
.1 r
Aquifer Storage and RecoveryISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test r.11 IStonnwater Drainage ft.
:)Experimental Technology MSubsidence Control ft. ft.
__.Geothermal(Closed Loop) r.1ITracer 20.DRILLING LOG(attach additional sheets if necessa
El_ FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc.)
Geothermal(Heating/Cooling Return) _.I IOther(explain under#21 Remarks) 0 ft. � ft.
4.Date Well(s)Completed:rl—iu--�ib Well ID# ft. t, ft.
Sa Well Location:
1 r� ft. 0 ft.
P�Var&n \A ft. 7 ft. 3-a n; C rn`lX
ft. ft. C
Facility/O1wnerNamoe Facility ID#n(ifQapplicabl(�e) JC
1� 1�k 1i1 Y 1� 1V� Qt O�3 I ft. ft.
Ph sical Address,City,and Zip
ft. ft.
(\ �n� 21.REMARKS 7
County \ C• Parcel Identification No.(PIN) l 1021
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 IT
5,�9r ) N JgD kq ' g) W �✓ 1''LQ'O��
6.Is(are)the well(s) permanent or OTemporary Signature of Certi Well Contract Date
7��` 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: nYes or J J�'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 and explain the nature of the copy oflhis 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 dierent(example-3@200'aannd 2@I00') construction to the following:
10.Static water level below top of casing: O (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service,Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 241b.For Infection Wells: In addition to sending the form to the address in 24a
.Well construction method: Mma
above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
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: IM 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: l 1 Amount: completion of well construction Ito 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