GW1-2021-00789_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14,WATER ZONES
Well Contractor Jame FROM TO DESCRIPTION
QQ ft. 3 ft. � h
cXD3 IT ft. � ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER(if a licable
��.1 1`t '`-' � I n�pf11 (��1 11( FROM ft. TO ft DIAMETER t" THICKNESS MATERIAL
Company Name V`1 \J t I '1 +, , q
_e j��(� l 16.INNER CASING OR TUBING 'cothermal closed-loop)
`
2.Well Construction Permit#: / Q,M —OL�OW) 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):
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_ AgriculturalMunicipal/Public ft. 33 ft. a I'" \o� yO P V�
Industrial/Commercral I esidential Water Supply v
(Heating/Cooling pp y) pp y(single) ft. ft. in.
GeothermalmerSupply) Residential Water Supply(shared) 18.GROUT. C
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D
ft. ft. � /�� _
__I Monitoring Recovery
Injection Well:
ft. ft. i
_ Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a_.licable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [MIStonmwater Drainage Q0
Experimental TechnologyISubsidence Control
Geothermal(Closed Loop) rMITracer 20.DRILLING LOG(attach additional sheets if fi&essa'
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
i Geothermal(Heating/Cooling Return) �(Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: OI o Well ID# ft. ft.
SanWell Location:
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Physical Address City,and Zip
'�arn,o51r1 1 Lt 013 q) 3 "17A 21.REMARKS
County Parcel Identification No.(PIN) D
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification
35 .af&-f40.i N _5 3a IDLe W � g - '$ ---I
6.Is(are)the well(s)Ppermanent or OTemporary Signature of rtified Well Co tractor 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: [)Yes or ®1J'AYO with 15A 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 a`ff�d 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. I
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: 2 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 33 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(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,use"+" 1617 Mail Service lCenter,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection 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: V'Y\U 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 I Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: t C� 24c.For Water Supply&Iniection Wells: In addition to sending the form to
1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: IL4 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