GW1-2021-00802_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Norge FROM I TO I DESCRIPTION
A� Q3 6 1 ft. 14 ft. C
- ft, ft.
NC Well Contractor Certification Number
< ^,D \ t 15.OUTER CASING(for multi-cased wells OR LINER(if a licablc
r��`1� XJ �'\C.�1 D� V(� FROM TO DIAMETER THICKNESS MATERIAL
Company Name v ` I ft• r� ft.
✓� 16.INNER CASING OR TUBING eotherntal closed-loo i�
2.Well Construction Permit#: W� oZ'a-� E� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. VIC,County,State, Variance,etc.) ft. ft. in.
----------------
3.Well Use(check well use): ft,
in.
Water Supply Well: 17.SCREEN
FROM TO DL4METER SLOT SIZE THICKNESS MATERIAL
_.Agricultural �Municipal/Public ft. aA ft. a in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) 1`
ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: © ft. ft. �� �
Monitoring nRecovery ft. ft.
Injection Well: d U r-
A uifer Recharge ft. ft.
- q g Groundwater Remediation
A uifer storage and Recovery 19.SAND/GRAVEL PACK(if a licable
q g ry OSalinityBarrier FROM TO MATERIAL EMPLACEMENT METEOD
Aquifer Test 0 Stormwater Drainage �� ft. �� ft.
Experimental Technology r.IISubsidence Control
Geothermal(Closed Loop) CITracer 20.DRILLING LOG(attach additional sheets if necess )
Geothermal(Heating/Cooling Return) lOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rack a rain size,etc.)
ft.
2 r l
4.Date Well(s)Completed: ' >D' v�Well ID# c� ft. Q ft. 1cA CN `
5a.`Well
1Location: Qom, b ft V ft. 1 CA
ft-
CX
Facility/Own r Name Facility ID#}(if applicable) ft. ft.
Physical Address,City, Zip �10 33 ft. ft.
Sarni ILA Old or-'�A wp 21.REMARKS
County Parcel Identification No.(PIN) npO
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat//long is sufficient) 22.Certification
3� r 1e4�3 N l O r "f� W
� � � ca •30�.�
6.Is(are)the well(s) Permanent or MTemporary Signature ofCertifi6d Well ContractilDate
By signing this form,1 hereby certfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes orNo with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information 46n3explain 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
9.Total well depth below land surface: 4 (fG) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3(,200'a»d 2@100')
construction to the following:
10.Static water level below top of casing: (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: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method:_ ��(�-kq \�, 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) p Method of test: U 24c. For Water Supply&Iniection Wells: In addition to sending the form to
l the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: / completion of well construction to the county health department of the county
where constructed.
Form GW-I Nortli Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016