GW1-2021-00622_Well Construction - GW1_20210326

11111\1 VIM
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
�m6tn \ oo /V 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
n.
ft. fl,
NC Well Contractor Certification Number IS.OUTER CASING tior molti-cased wells OR LINER if applicable)
\ImMk F tilt Gf-ftC 2001g wLL Co FROM TO DLIMETER TRICKNESS MATERIAL
f[. n. in. Yr
Company Name V
332iS� RCASING ORTI RING ER mat cl TUCKdao
2.Well Construction Perini[#: FROM TO DIAMETER 1'FIICKNESS MATERIAL
.
Litt all applicable well construction permits(i.e U/C,Counryt State. Variance,etc)State.
3.Well Use(check well use): ft. ft.
Water Supply Well: 17.SCREEN
PPY FROM TO DIAMETER SLOT SIZE THICKNESS MATEp1AI
Agricultural ©M a unicipal/Public . n, in.
Geothermal(Heating/Cooling Supply) b4idenlial Water Supply(single)
Industrial/Commercial ®Residential Water Supply(shared) tE.GROUT
Irri ation FROM 1 TO MATERIAL 1,n EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft' 1 n' ll nit� VI
Monitoring Recovery ft. n. %-4511,
Injection Well:
rt. n.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK La Ica
Aquifer Storage and Recovery QSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ©Stmrmwater Drainage
Experimental Technology Subsidence Control D, ft.
Geothermal(Closed Loop) ®Tracer X DRILLING LOG attach additlaod sheets if necessa
FROM TO DESCRIPTION robe M1nrdneq wlVroek nilnslr etc.
Geothermal(Heating/CoolingReturn) Other(explain under 421 Remarks 0 II '1
4.Date Well(s)Completed: 3 12.E 21 Well ID# L ft. <' ft' G)
U it 0 n, S ri h
Sa.Wee-R(Location: �('
P G I C-IMU n, � o ft. 1 qr-qn4e, ack
Facility/Owner Name Facility lD#(ifappliceble) ft. ft.
495 C RNES 1 -zekli.oN NC 1-93 n. n.
Physical Address,City,and Zip I ft. ft.
I r0.r, n 21.REMARKS
r I 9
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lallong is sufficient) 22.Certification:
N W
6.Is(are)the well(s) Permanent or ®Temporary Signature of Certified Well Contractor Date
By signing thisform, 1 hereby certifv that the wells)was(ware)constructed in accordance
7.Is this a repair to an existing well: [Dyes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
1f this is a repair,f ll our known well construction information and esploin the nature of the copy of this record has been provided to Ole well owner.
repair under#21 remarks section or on the back ofrhis 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
construction only 1 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: 910 O (ft,) 24a, For All Wells: Submit this forth within 30 days of completion of well
For multiple wells IW all depths iflhffrreut(example-3@200'mul 2@1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
if wurer level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the forth to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: Q construction to the following:
(i_e.auger,rotary,cable,direct push,eta)
Division of Water Resources,Underground Infection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) W Method of test: iif Q� 24c. For Water Supply& Injection 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: a N Amount:I k completion of well construction to the county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2010