GW1-2021-00784_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
ILIW Ty 14:WATER ZONES
Well Contractor Nan. FROM TO DESCRIPTION
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER(if a usable
✓� < FROM TO DIAMETER TffiCKNESS MATERIAL
L 1 a , ft. ft. in. G L f (�
Company Name
16.INNER CASING OR TUBING "cothertnal closed-loo`
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, it. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public 3 ft. ft. ` D\A 40 Pic,
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. i❑.
Industrial/Commercial Residential Water Supply(shared) --
18.GROUT
lrTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. Q ft.
MonitoringRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a Mablc;
Aquifer Storage and Recovery ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_ Aquifer Test I Stonnwater Drainage V ft. S , ft. Ia �� r
Experimental Technology []]Subsidence Control tt. ft.
Closed Loop) ]Tracer 20.DRILLING LOG(attach addifTonal sheets if n( p) � ecessa" '
FROM TO DESCRH'TiON(color,hardness,soil/rock e, rain size,etc.)
BGeothermal Geothermal(Heating/Cooling Return) Ell (explain under#21 Remarks) ft. � ft.
4.Date Well(s)Completed: 5 X)Well ID# ft. ft.
5a.N
ft
Location: f[. , �( . Gt I,l t�i
�� 1 ft. 3 v ft. t&1i�� Gl
Facility/Owner NvIne
�� Facility ID#(if applicable) ` 3 ft. ft.
l \ Yti s n
\lA � �l1 I A� ft. ft. !
Physical Address,City,and Zip ft. ft.
l`] 21.REMARK
County \ l" Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(iiff�well field,one lat/long is sufficient) 22.Certification:
JrJc' OQ A 3' N -Ne Iq• -c W
6.Is(are)the well(s) Permanent or OTemporary Signature of C fied Well Co❑tr for Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EIYes or Mo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information Ad 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
f
9.Total well depth below land surface: 5 A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,us "+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection 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: U� <<l7Stl1(� 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
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13a.Yield(gpm) Method of test: l vm�io I 24c.For Water Supply&Injection 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 I/7i completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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