GW1-2021-00795_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information':
14.WATER ZONES
Well Contra f�Name
FROM TO DESCRIPTION
.� 3 ft. rsanj
ft, ft.
NC Well Con ctor Certification Number
i IS.OUTER CASING(for multi-eased wells)OR LINER(if a licablc
�D 1 FROM TO DIAMETER THICKNESS MATERIAL
Company Name l/` Y t•-I ft. Q ft. � in. son 0 PVC
.p��-y��-� 16.INNER CASING OR TUBING eotherntal closed-loop)
2.Well Construction Permit#: V S, �1 l�l��A�� FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well cotsnvction permits(i.e. UIC,County,State, Variance,etc) ft. ft. I in.
3.Well Use(check well use): . ft ft. I in.
Water Supply Well: 17.SCREEN
7 3FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural �Municipal/Public $9 fI 3 ft. in. SC O PV
Geothermal(Heating/Cooling Supply) F esidential Water Supply(single) ft. ft. in.
industriaUCommercial DResidential Water Supply(shared) 18.GROUT
_ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. Q0
Monitoring ORecovery
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
_ Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage u ft. 3 fL
Experimental Technology OSubsidence 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)
('1 fL ft
4.Date Well(s)Completed:0_ a 1 Well ID# , ft. Q fL
12
ft. u
Sa.Well
`pLocation:� 1 1 j^` ('
Cb l�l U\ 1 V1' ft� 1-1
ft. ft. Y� 0,CIS
Facility/Owner Name �F(aciility ID#(if applicable) 3 P ft. ft. a i
IN &Dy �,\yy1 �VjjR� {I I I}'x av ft. 199
ft. ^
Physical Address,C ,and Zip Cp 1, f[. CkUUA Sa
2I.REM l
ARK.0
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
DEC 8 2 221
(if well field,one lat/long is sufficient) 22.Certification:
-� pa:jl
6.Is(are)the well(s)MPermanent or IiTemporary Signature Certified Wqn Contracto Date
IN No
signing this form,1 hereby cert fin that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or No 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 it formation nd 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.
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: S
Q` SUBMITTAL INSTRUCTION
9.Total well depth below land surface: I (it-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells Cut all depths ifdiffereni(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 Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
.Well construction method: �1��VV MUA 'RT Vuk above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: V m 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
1/�
13b.Disinfection type:1'1 Amount: 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