GW1-2021-00729_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well
4nContractor Information:
14.WATER ZONES
Well Contractor Ne aht
FROM TO DESCRIPTION
p ft. ft. Cbdrse 4priSGI A
O � ft. ft f
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a livable
FROM TO DIAMETER TBICKNE'S MATERIAL
Company Name r' ft. h ft in. C'1_ �O
16.INNER CASING OR TUBING eotherntal closed-too
2.Well Construction Permit#: -') FROM TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e. VIC.County,State, Variance,etc.) ft ft. in.
3.Well Use(check well use): . ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
Agricultural [3Municipal/Public ' I ft IL in. I a t LO
Geothermal(Heating/Cooling Supply) residential Water Supply(single) 1 ft. ft. in. `i
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fc. 1t
Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if a 'livable
_ Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test MStormwater Drainage ao ft u fL
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) rlITracer 20.DRILLING LOG(attach additional sheets if necessary)
_ Geothermal(Heating/Cooling Return) Ml Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock a rain si eta)
k ft / ft f p s-Q
4.Date Well(s)Completed: 1`aa-� Well ID# ' ft. !G ft. L Gi
GT ft. Ic! ft. U
Sa.Well Location: I !J n LA
� p
G)
(�1 �Q �( ft. e�e1 ft U� i I a� rl I i Ci
Facility/Owne4 Name l/l/ Facility ID#(if applicable) v ft. ft.
y0 k n s aJn
G/dt
PhysijaJ Address,Ci ,and Zip IL
fL L+ oay-&e 1
21.REMARKS DECCounty Parcel Identification No.(PIN) J1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification
M" 5� 1153 N �q° I , 3 I W '.
6.Is(are)the well(s)OPermanent or Temporary Signature ofCert ed Well Con or T Date
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: [3Yes or Wo with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Consintciion Standards and that a
lfthis is a repair,fill out known well construction information and 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 1 GW-I 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 ifdfferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 0?3 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use +" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �0 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
11.Well construction method: U,& 1N`
nbj7a 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 SUPPLCY�WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) `t Method of test: U C11 M 24c. For Water Supply&Iniection Wells: In addition to sending the form to
—( I the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1 A 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