GW1-2021-00843_Well Construction - GW1_20210322

Ill I VIIII
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
J Aso1V \ oo L� 14.WATER ZONES
Well Contractor Name
rt1 FROM TO I DFSCmPTION
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OA LINER if Heable
?V1 - Na Co FROM I TO I DIAMETER I THICKNESS I MATERIAL
n. R.
Company Name
V
332�89 ER CASI G OR TUBING mthermai clmed4w
2.Well Construction Permit#: `� 1 FROM Tc DIAMETER THICKNESS MATERIAL
List all applicable well construction permits/.e. VIC, Count',State, Variance,etc) f1. ft. in.
3.Well Use(check well use): ft. ft. la
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural [)Municipab'Public ft. ft. in.
Geothermal(Heating Cooling Supply) Q<esidendal Water Supply(single)
ft. R. in.
Industrial/Commercial ©Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL y� EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: I. y a n, nl{f. 1
Monitoring Recovery ft. ft. -{+
Injection Well: R a
Aquifer Recharge [)Groundwater Remediation 19.SAND/GMVEL PACK Ha
Aquifer Storage and Recovery [)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stornwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. n.
Geothermal(Closed Loop) ©Tracer 20.DRILLING LOG fattach additional sheets If necessary)
Geothermal(Heating/Cooling Retain) MOther(explain under#21 Remarks) roots I TO DES"P ION error,hudn .amrock tyu,gmin rla de.
0 n. R. -fv 9!
4.Date Well(s)Completed: _ Well DO 2. ft- R. G j
Sa.Well Location:
p D. p n. S tin M
P E1M. G U 60 Jgo It.. ran ✓ c
Faacilny/Owner N amc Facility ED (iifapplieablee)
49S CamUCS R1 -2egu V VC 1,p 3
Physical
Address,City,and Zip
NM
Ena�/\II KS n 21.REMARKS
t
� r--- Is,
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
ofwcll field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the wcU(s) Permanent or [)Temporary Signature ofCcrtified Well Contractor Date
By signing this(arm,I hereby oerGh that the arf!/s),vas,(were)constructed in accordance
7.Is this a repair to an existing well: [)Yes or No with 15A NCAC 02C.0I00 or 15A NCAC 02C.0200 Well Construction Standards,and that a
Ifthis is a repair,fill our known well cmutrucnan irnforsucl m and explain the nature of the cop)of this record has been provided to the well owner.
repair under#21 remarkv section or on the back of this farm. 23.Site diagram or additional well details:
g.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: I
/�L} SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /_ 1 O (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths it different(example-3@200'and 22A]00') construction to the following:
10.Static water level below top of casing: 2 l/ (It.) Division of Water Resources,Information Processing Unit,
If water level is above casing.we "+ ' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Inlection Wells: In addition to sending the form to the address in 24a
r'- above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1 a 1e.)
(i.c,auger,rotary,cable,direct p etc.) construction to the following:
ush
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) W Method of tesC Md\'l _ 24c.For Water Supply & IRlectlon Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: H rt N Amount: f� completion of well construction to the county health department of the county
where constructed.
Form GW-1 Nortb Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016