GW1-2021-00253_Well Construction - GW1_20210125

WELL CONSTRUCTION RECORD(GW-1). For Internal Use Only:
1.Well Co 66 n�yb(ofr madonA }_
14 WATER ZONES
WeUConuaaorName FROM TO DESCRIPTION
J0 y� R 6o ft.
R R
NC Well Connector rion Number M OOTER,CASILV(s(for, wells)OR LINER d
FROM TO DIAMETER THICKNESS MAIM L
ft. ft. in. C
Company Nam / 16-11NNER - i3R7ilBII!i[r'
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERIAL
List all applicabk well construction permits(Le.UIC.County,State.Parlance,eta) R 414 ft in.
3.Well Use(check well use): R VIF ft in.
Water Supply Well: _;1 SCREEN .. .
FROM I TO I DIAMETER I SLOTSTLE I THICKNESS MATERIAL
Agricultural IN Ipal/Public 0 ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R m
Industrial/Commercial 131tesidential Water Supply(shared) ..
_. Irrigation FROM TO MATERIAL EhTPLACEMENTMErHOD OUNT
Noo Water Snppty Well R fL
Bn
Monitoring Recovery R R
Injection Wen:
Aquifer Recharge Groundwater Remediation ft. ft.
19..SAND/GR,kVEL'PIIGH le
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test' 13Stormwater Drainage R
Expervnental Technology QSubsidence Control R 10 IV I R
Geothermal(Closed Loop) Tracer '.2&DRHJM*G:.LOG.alloch=WAwWiih6 ;
FROM I TO DISCRIPr7 eoloq hardness,wWrwit"N V!t sin,W-
Geothermal eatin Cool' ) DOther( lain under 921 Remarks
4.Date Well(s)Completed: 7 0� Wen ID# O R �N-
5a.Well Location: fr' R
R R
Facility/Gwaer Name F=Wffity ID#(ifapplicable) R R
fe` R R
Physical gddrCss,City,and i R fc
t 2LREMARKS
T—&A/V
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minatntseconds or decimal degrees:
(if well field,one bu/long is sufficient) 22.Certification:
W
6.ware)the wells) Permanent or [Tempo;ro
Signature of Certified ell or
By signing this form.1 hereby cerrrfy that the wells)was(were)constructed in accordance
7.TS this a repair to an existing well ®Yes or with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
lfdus is a repair,flu our Immm well aonstructton infornra ton and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks swatin or on the back of this form.
23.�to diagram or additional well details:
8.
ay use
e back of this
to provide
coFor Geoprobe/DPT nstrution,only 1 W-1 is needed. Indicater Closed-Loop tTOTALe NUMBER ofweils;r lls having the same ^,° toon'°uctio deteta&. You may also attachadditional pages al went site aryy. or well
drilled: .W
9.Total well INSTRUCTIONS
depth below land surface: a. For All Wens: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd0erent(exmnple-3 00'and 2@1001 n —=s-lt
A ?is'trt�c�"on to the following:
10.fwneStatic
water is above level lbtop of casing: �O ry` 1(fC), ,� +� Division of Water Resources,Information Processing Unit,
&use 11+
`i�G��1'"�:il•�n� 1617 Man 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
i ll foownabove,also submit one copy of this form within 30 days of completion of well
(i.e.i Well construction method: �y ��
( auger.roomy,cable,disco push,etc.) construction to the g'
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Man Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm)_ 42 C> Method of test DD
a 24c.For Water SDIv&Iniection 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: Amount completion of well construction to the county health department of the county
where constructed. f-`
Form GW-1 North Carolina Deparmunt of Environmental Quality-Division of Water Resources Revised 2-22-2016