GW1-2021-01404_Well Construction - GW1_20210329

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
IN)S�l.r, (_,rGk��,.��yl +`1. 14.WATER TONES
Well Contractor Name FROM TO DESCRIPTION
/s- n. 't1 D I
�1 AA
NC Wel Contractor Certification Number 461 fi / f/ f- - pr1
IS OUTER CASING for i aakPcaud
we0s OR LINER
MIOK Tory DIAMETER TRICIQM MMATERW.
Co/ ny Namc t ) IL 5-/ 6 ib 1 r) Xf 60
/ `/'I 0 16.INNER CASING OR TUBING el
2.Well Construction Permit#: (�JV FROM To DIAMETER TmcIQ.'Ess I MATERIAL
List all applicable well construction permits(i.e.U/C,Carmb,State. Variance,etc) ft. IL in.
3.Well Use(check well use): R. R. Is.
Water Supply Well: 17.SCREEN
PROM j TO I DIAMETER I SLOTSIZE I THICKNESS MATERIAL
❑Agficultmal ❑//Municipal/Public n. H. la.
[]Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) ft R. I.
❑In lusnial/Commercial []Residential Water Supply(shared) It GROUT
OIrrigation ❑Wells>100,000 GPD FROM TO MATFAUAL EMPLACEMKNTMETROD&AMOUNT
Non-Water Supply Well: TO- Zi) R plc /,/' Jadr
OMonitoring ❑Recovery R. fL
Injection Well:
a R.
OAquifer Recharge ❑Groundwater Remediation
OA uifer Storage Recovery []Salinity Barrier 19.SAND/GRAVEL PACK(B
q B �y fY FROM TO MAi F,R1A1. I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft H.
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets Ifneeesu
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) mom TO DPsrItUvRON mane harineu,tomtvcs tw,India ets.
4.Date Wells)Completed:3 1 2/ Well ID# r- R ft tn -Q
So.Well Location: L.v`
A'-' !
Facility/Owner Name Q Facility ID#(if applicable) ft. ft (1 20
21
GJ Y• �4�. ��k_n��� l�i� �_���� Q.�� (L R 7 - 1it11
Physma Address,City,and Zip
�,�} f,tn 21.REMARKS
J, r
County Pamrol Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/mconds or decimal degrees:
(if well field,oce IaGlong is sufficient) 22.Certification:
6.Is(are)the well(s): MPermanent or []Temporary Sl am of Certified Wd Contractor Data /
� By signing thisform.I hereby curtly that the well(s)u s(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IZfNo 15A NCAC 02C.0/00 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
lfthis is a repair fill nut/sown well construction information and explain the nature of the ofthu record has been provided to the well owner.
repair under#21 remarks section or on the back o(tbis 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 I GW-I 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: L z S (ft)
For multiple wells list all depths if different(example-3@,200'and 2@1003 Submit this GW-1 within 30 days at well completion per the following:
10. fit 24a. For AB Wells: Original form to Division of Water Resources (DWR),
/J u nter/eve/is above casing use Static water level below fop of using: ( ) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
"-"
11.Borehole diameter.
24b.For Injection Wells: C to DWR,Underground Injection Control IUC)
(in.) N )Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: fo
II A 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,mrary,cable,dvat paslc etc.) county environmental health department of a county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells E-al ae over 100.000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) S Method of test: .i D r'�
13b.Disinfection type: Amount: /L
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 652018