GW1-2021-00765_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: �.J
�A rru W,111 ( 1 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Nam
2`4l��a
ft. ft.
`NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR LINER if a Gcable
! ^1'1 w j \ ' I �'�'1^ FROM TO DIAMETER THICKNESS MATERIAL
U y 1 y y 1 , ` t ft. 1 I. 91 ft. A in. S h t LV 1-a P'vG
Company Name ` 1 L 't
16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,9tate,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FROME TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 49.ft. 5 ft. a in. ( q0 q L c
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 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 ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control
❑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.)
O ft. ft. 1'
4.Date Well(s)Completedq Well ID# ' ft.
ft. ft. c. _W 91 1
5a.Well Location: T
MhaM (L t►-t ft. fL µ
Facility/Owner Name ,, Facility IDn#`(if applicable) V 1 ft. fL Yam\
IS 1 1 U rn� yew S� p1J1�`� 1 t71 O ft. fL
Physical Address,City,and Zip I ft. A8 2U t
_��bpnD r.. p no try' 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
3q t 'I ft g l l(P N �` 9 I C1 3_S4 q q W W r
6.Is(are)the well(s): Lermanent or ❑Temporary Signature ofCe0fied Well Contrictor Date
��_�////1111 By signing this farm,!hereby certifi,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or No ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a cop),
lfthis is a repair,fill out known well construction information a,/d 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-1 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: 5 q (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
If Static water level below top of casing: (ft*) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
!f water level is above casing,use"+"
11.Borehole diameter: (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(fUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: My,& 1CAl�Y�/� 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) T Method of test: 1
13b.Disinfection type: 1� Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018