GW1-2021-02115_Well Construction - GW1_20210709

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
"14.-WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ASC�ft. IL
NC�IlContracto Certification Number CE1V f4
15.OUTER CASING for muldxased wells OR LINER'if alp
°liable
\ O 9 OM TO DIAMETER THICKNESS MATERIAL
•1 ` `coo- 1,11 2 fL C ft a Sin. v(-
Company Nam J I+
�e-4c\o— CASING OR TUBING iliermat closeddoo` -
2.Well Construction Permit#: ormation Pfoces TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance, ft. tq is
3.Well Use(check well use): tt ft in.
47.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public tt. L in.
❑Geothermal(Heating/Cooling Supply) $49idential Water Supply(single) f� fy in •
❑IndustriallCommercial ❑Residential Water Supply(shared) 18.GROUT
❑irrt ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft v ft. 1 i oL S
❑Monitoring ❑Recovery ft. It.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVELPACK da liable .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft,
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets it necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,son/roekMm gr%M size,etc
d ft.
av ft. Ct ,
4.Date Well(s)Completed: -2 Well ID# a ft R
tt ft.
5a.Well Location:
Facility/OwnerName Facility ID#(ifapplicabk) f• ItAl
R'
►?� �W%AV� NC& fir'.VDQc�c�l�Q FL 229 -1 ft.
Physical Address,City,and Zip R ft
��( c��/.jZr 1—�y►1— — 4( 3 zi.Rr1vfARI�s
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22. fi ation:
�S 1l9•y�1y N -�-1 O$ . �1 l� W 6 -2 4
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified ell ntractor Date
/ By signing this form,I e certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or flQNo 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add,See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: ` 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: —I C) (ft.) Submit this GW-1 within 30 days of well completion per the following:
For mul(i�le weUs list all depths ifdifferent(example-3®200'and 2@100)
�Q 24a. For All Wells: Originat form to Division of Water Resources (DWR),
10.Static water level below top of casing: o (D•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use
11.Borehole diameter: (in,) 24b.For Injection Wells:Copy litoiDWR,'Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 276994636
12.Well construction method: �. t� \t \� 24c.For Water Supply and en-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental heal epattm co ent of the county where sta ed
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
�� Permit Program,1611 MSC,Ralcrgh,NC 27699-1 11
13a.Yield m �\ ` Method of test:
13b.Disinfection typk X1`6f 1 YM Amount:
I
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resou i s Revised 6-6-2018