GW1-2021-01167_Well Construction - GW1_20211223

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
�'P6 700n,�� 1 A>l`i 14.WATER ZONES
Well Contractor Name FROM To DESCRIPTION
ft. ft.
go C- 'AWS ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Bcable
` ,�,� 1 , ( (1 FROM TO DIAMETER THICKNESS MATERIAL
1 1 - R N J cAk A 21 1 I 1 by �.1i C, ft. 1 ft in.
Company Name �h^ 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#:�(1 f ROX DOa c/�{ 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 DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring DRecovery ft. ft
Injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery n Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology ®Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) MOther(explain under#21 RemarksLJ
FROM TO DESCRIPTION(color,hardness,soittrock type,grain size,etc.)
�f �/ It. r It.
4.Date Well(s)Completed:1���.1l�- f- Well m#�1Y�o 02_00 E" tt. I ft. ad
I ft. ft.
5a.Well Location:
ft.Fyn
ft.
Facility/0-Name Facility ID#(if applicable) ft. ft.
AnQeRc. A �
Phy Address,Ct p I
rhPm\ 21.REMARKS fftt..County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W t
cw� Irl
6.Is(are)the well(s) Permanent or Temporary i ture of Certified Well Contractor Date
Illjjj"�����T B signing this form,I hereby cert6 that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes orNo th 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 inform or
and 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
constructioq,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 SUBMITTAL INSTRUCTIONS
I
9.Total well depth below land surface: I ULQ (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: `-F(J (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,usre^"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 11J (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:W 1 Z �I - 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
np
13a.Yield(gpm)�a Method of test: A lt k 24c.For Water Supply&Iniection Wells: In addition to sending the form to
ZZ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:V& PIPAIA5 Amount: lJd 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