GW1-2021-00788_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: j
rru u ilk ifDl i -Sr
14,WATER ZONES.
Well Contractor Name FROM TO DESCRIPTION
s
a��3 '� a ft. �o ft. arm
ft. ft.
NC Well Contracto Certificnation Number 15.OUTER CASING for multi-cised wells OR LINER if a licablc
�` ,; � '/ n'��' ✓t1�i FROM TO DIAMETER THICKNESS MATERIAL
7 V V ` ft. a ft. in. 5CA.,%_\O I VC
Company Name 16.INNER CASING OR TUBING' bthermal closed-loop)
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. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAM TER SLOT SIZE THICKNESS MATERIAL
_!Agricultural MiResidential
Municipal/Public a17 ft. 4D ft. in. C)IQ Schya V(-
I Geothermal(Heating/Cooling Supply) Residential Water Supply(single) f f ;in.
Industrial/Commercial Water Supply(shared) 18.GROUT.'
_ Im ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. �l� ft• ��,(�}+pn'AC
Monitoring Recovery ft. oC ft.
Injection Well:
_ Aquifer Recharge ElGroundwater Remediation
19.SAND/GRAVEL PACK if a lieablc
Aquifer Storage and Recovery C]ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStorrnwater Drainage aQ ft. ( ft #a' ukr
Experimental Technology []I Subsidence Control
Geothermal(Closed Loop) ITracer 20.DRILLING LOG(attach'additiotial sheets if necessi`
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
__i Geothermal(Heating/Cooling turn) Other(explain under#21 Remarks) FROM
ft. —�
4.Date Well(s)Completed: V Well ID# ft. t ft. S
5a.Well Location: 1 ft. ��ft• 0_V 1 d
SIllli U'l/1 ti 1 \t U D 0 ^Y a ft. a ft.
Facility/Owner
Nta�m(ey�� Facility ID`#((if applicable)
i u�T�V V,►rA 1 1 \)1 1�`�^v ft. �V�/ft.
Physical Address,City,and Zip
00a 01 U01 21.REMARKS l
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) p 22.Certification:
,5® 13 s 5 1] N t1 O° 3a•(�,5 1 (-P W
6.Is(are)the well(s) ermanent or OTemporary Signature of C66fied Well Con ctor Date
777 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: EIYes or LVNo with ISA 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 nd 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: (l SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: q0 (ft.) 24a. For All Wells: Submit dliis form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: b (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+"" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: y (in.) 24b.For Irliection Wells: In addition to sending the form to the address in 24a
above, also submit one copy ofjthis form within 30 days of completion of well
12.Well construction method: rMA 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
13a.Yield(gpm) O(o Method of test: o l 24c.For Water Supply&InieI tion Wells: In addition to sending the form to
( the address(es) above, also sulimit one copy of this form within 30 days of
'
13b.Disinfection type: I Amount:_ completion of well construction)to the county health department of the county
where constructed.
0
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016