GW1-2021-00764_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:y V,k 11 1 �� 1�/
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractors Name
g
dl
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a 6cable
FROM TO DIAMETER THICKNESS MATERIAL
-} 1 ft. ft. in. 'SL�L 0 PqL
Company Name J 16.INNER CASING OR TUBING( eothermal closed-loop)
3S� �13 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:
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 v).I ft. O ft. ^l in. b "1 0'
10 [wc�
❑Geothermal(Heating/Cooling Supply) Xesidential Water Supply(single) O ft. O� in.
❑Industrial/Commercial EI__Residential Water Supply(shared) 18.GROUT
❑Uri ation ❑Wells> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: v ft. O ft.
❑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 C9 0
ft. 9q ft. Z
❑Experimental Technology ❑Subsidence Control ft. O t ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DEJCRIPTION(color,hardness,soiUrock type,gmin sim,etc.)
O ft. OC/1 ft. .
4.Date Well(s)Completed: 1�"1 ?� Well ID# ft. ft. dy Q
5W,�ell Location: ft. � ".
Well
'1o�A 19t. 3 et. n
Facility/Owner
Name
v Facility ID#(ifapplicable) ft. ft. U� `i 1 C'/ii
ft. ft.
Physical Address,City,and Zip OEC p` �
RV�SbY\ 1 O top ()DQ 21.REMARKS -'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3'E t lr�t�31TN t Qk 1381 w
A
6.Is(are)the well(s): E�, 'rmanent or ❑Temporary Signature ofCeftified Well Co tractor Date
By signing this form,1 hereby certifi'that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well- ❑Yes or �No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a cope
If this is a repair,fill out known well construction information a4d`explain the nature of the of this record has been provided to rite 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 I 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 ifdifferent(example-3@200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (in,) 24b.For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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: V I rA
13b.Disinfection type: Amount: I�
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018