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Home My WebLink AboutGW1-2021-00184_Well Construction - GW1_20210505 WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1.Well Contractor Information: I0 Ak FROM TO DESCRIPTION �well Contractor Name n`4� n 4r+ `L -5 C L ft. G tit. NC ell Contractor Certification Number "15.O11'ER'CA51NG'for""'' "` FROM TO DIA11tE1ER Yffi[CIQtFSS MATERL►L �- & -1 & ComAany New 2/) 2 1��IlVNER`GASING'OReTOBING_ tbeei�t� 2.Well Construction Permit#: Jv J FROM To DL4MKr'ER I THICKNESS Mi►TER►AL List all applicable well construction permits(i e.UIC,County,State,Variance,etc.) 3.Well Use(check well use): It, ft hL Water SupplyWell: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ❑Agricultural ❑M cipal/Public ft. ft. In. ❑Geothermal(Heating/Cooling Supply) 131Residential Water Supply(single) g, M in ❑ludustrial/Commercial ❑Residential Water Supply(shared) a 18.aGROUTrts...,....� ' - Ohri ation [:]Wells>100,000 GPD FROM To MATERIAL I MPLACEMENT METHOD&AMODNT NoaWater Supply Well: ft ft. tin ,C ❑Monitoring ❑Recovery ft. tit. Injection Well: it. ft. ❑Aquifer Recharge ❑Groundwater Remediation vi19.�Air1D/GRAN�IP!F.AtK? e` . ❑Aquifer Storage and Recovery ❑Salinity Barrier EFROM TO MATERW. EMPLACEl1ffiIiM ITIOD ❑Aquifer Test ❑Stormwater Drainage % ❑Experimental Technology ❑Subsidence Control % OGeothetmal(Closed Loop) ❑Tracer❑Geothermal eatin Cooling Return ❑Other(ex lain under#21 Remarks TO DESCRIPTION eobr hardn soWrock eta 4.Date Well(s)Completed: ` Well ID# 6 R' 0.5a.Well Location: Zgo �' No(+h ��alo�lnfi �'��l�fS ft' n' ility/Owner Name �/� Facility ID#(if applicable) k" ft. ft. ,A 0 2021 c oral JDr- Ff-Q1,M' ft. tit' Ph ical Address,City,and Zip fL M (j};`{f R"^-c A it ' 2E'4EA1ARKS county Parcel Identification No.(PIN) 041 r+ 5b.Latitude and longitude in degreestminutes/seconds or decimal degrees: (if well field,one lat/long is sufficient) 22.Certification: // N W ?_02 6.Is(are)the well(s): OPermanent or OTemporary 'Signature of cafiedweli Contractor Date _// By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with 7.Is this a repair to an existing well: ❑Yes or 0No 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 well Construction Standards and that a copy #'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 I GW-1 is needed. Indicate TOTAL NUMBER of wells ( See Over in Remarks Box).You may also attach additional pages if necessary. filled' ^ 24.SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: do For multiple wells list all depths if different(example-3 t@200'and 2 a@1001 Submit this GW-1 within 30 days of well completion per the following: 10.Static water level below top of casing: 30 ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR), if water level is above casing,use"+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 11.Borehole diameter: b/ (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) Program,1636 MSC,Raleigh,NC 27699-1636 1L Well construction method: !`EJ to rY 24c,For Water Supply and o-I Geothermal Return Wells:Copy to the (Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells rodudn over 100 000 GPD:Copy to DWR,CCPCUA Permit Program,1611 MSC,Ralei NC 27699-1611 13a.Yield(gpm) Method of test: 6 13b.Disinfection type: _ Amount: Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2018 WELL CONS TRUCTION RECORD GW-1 For Internal Use Only: 1.Well Contractor Into tion: 14'WATER,7.0NES. FROM TO DFSCREMON Well Contrwmr Name 0 ft- 2-31 ft. ft. NC Well Contractor Certification Number ,':15:OU7'ERCASING;fai�ntiNi-ea'""�sed:-w`�li;17R; 7 FROM TO DIAMETER THICKNESS MATERIAL P (bA �. 6 9 tw 6 '°. . / Gal van�2ed Com6nyName J I 36:INNER"Gi181NG,ORa'UBING: "� , 2.Well Construction Permit#: `^`� FROM TO DrAMETER THICKNESS MATERIAL List all applicable wrll construction permits(Le.UIC,CDU11ty,State,Variance,etc) ft• ft' in. 3.Well Use(check well use): it. ft. in. Water Supply Well: FROM I TO .z: D Ra SLOT SIZE THICKNESS MATERIAL j ❑Agricultural ❑Municipal/Public it. it. in. ❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in. ❑ladustrialtCommercial ❑Residential Water Supply(shared) ulS IAtUITf ❑Irri tion ❑Wells>100,000 GPD FROM TO MATERIAL;;�EMMCEWM1W0D&AM0UN; Non-Water Supply Well: Q ft. '2-0 ft. PAIK OMonitoring ❑Recovery ft. ft. Injection Well: ft. it. ❑Aquifer Recharge ❑Groundwater Remediation '_`19.'•S31itYD/GRi►V,EI�P,iiGtC' e'. ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL I EMPLACEMENT METHOD ❑Aquifer Test ❑Stormwater Drainage ft. ft. ❑Experimental Technology ❑Subsidence Control It. % ❑Geothermal(Closed Loop) ❑Tracer 2o.AR113fINGLl7G,tttReti=addItWWO'W hOiiieeesei . ❑Geothermal(Heating/Cooling'R/eturn ❑Other(explain under#21 Remarks) ROM D m TO ESCRIrnOx color, ran wwmek ete. 4.Date Well(s)Completed: 7 Z� Well ID# iv fL 5 3 f S f"' 5a.Well Location: M s c�and M cNa I T V ft. ft. Facility/Owner Name IFacility ID#(if aprfile) ft. IL q06 M m1)nf o wef C,L,t/r�d, ft. ft `r vy .,•. an�� v, ;C�u Physical Address,City,and Zip ft ft h 2E�REM ARHS . County Parcel Identification No.(PIN) tkck A a . d 44DriVe e 5b.Latitude and longitude In degrees/minuteslseconds or decimal degrees: (if well field,one Wong is sufficient) 22.Certification: N W 6.Is(Are)the well(s): permanent or ❑Temporary Signature of Certifi d Well Contractor 13ate By signing this form,Ike-by certify that the well(s)was(were)constructed in accordance with 7.Is this a repair to an existing well: ❑Yes or JNo 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy ff this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the will 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: l�(� 24.SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: /J (ft) For multiple wells list all depths if different(example-3a@22000'and 2@1001 Submit this GW-1 within 30 days of well completion per the followlug: 10.Static water level below top of casing: 24a. For All Wells: Original form to Division of Water Resources (DWR), if uwer level is above casing,use-+ Information Processing Unit,1617 MSC,Raleigh NC 27699-1617 11.Borehole diameter: 6 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC) Program,1636 MSC,Raleigh,NC 27699-1636 1L Well construction method: fe-d T0.r y 24c.For Water Supply and Opeo-Loop Geothermal Return Wells:Copy to the (i e.auger,rotary,cable,direct push etc.) county environmental health department of the county ere`wed FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells rodudn over 100 000 GPD:Copy to DWR,CCPCUA Permit Program 1611 MSC,Raleigh,NC 27699-1611 13a.Yield(gpm) Method of test: ''J 13b.Disinfection type: H-rig /Amount: 1 41) Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised&&201 S WELL CONSTRUCTION RECORD(GW-1) For Internal Use Onty: 1.Well Contractor Information: The y� I 15ti FROM TO DESCRIPVON Well Contractor Name ft. ft. NC Well Cortbactor Certification Number 15�U1 ER EASING fo�amtilH eased � 4I O O TO D TRICKKM MATEBIAL CampanyName s /9g U4� �3 161INNER-CA81DiGrUReTI1B v DIAINGMETE-rR. , .- , 2.Well Construction Permit#: FROM TO TMCKNEss MATEM' List all applicable well construction permits(i e.WC,County,State,Variance,etc.) ft. fL In 3.Well Use(check well use): fL ft fir. Water Supply WeIl: FROM s I DIANNIER `sf oT s>� rmclavFss MATERIAL ❑Agricultural ❑Municipal/Public tt. 6t in. ❑Geothermal(Heating/Cooling Supply) Ellre—sidential Water Supply(single) ft. & is Olndustrial/Commercial ❑Residential Water Supply(shared) ❑lrri ation ❑Wells>100,000 GPD FROM To MATERIAL Fnmi AcEnm" oD&AMOUNT Non-Water Supply Well: 0 ft• a 6 ft (P 0 u T c- ❑Monitoring ❑Recovery ft. ft. Injection Well: ft. ft. ❑Aquifer Recharge ❑Groundwater Remediation ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACENDUfr METHOD ❑Aquifer Test ❑Stormwater Drainage ft. ft. ❑Experimental Technology ❑Subsidence Control ft. ft, ❑(ieothermal(Closed Loop) ❑Tracer 20.,DR1lLLJNG;UA)G1 attiW4ddttionilsltlEta7 ❑Geothermal(Heating/Cooling Return ❑Other(explain under#21 Remarks FROM TO DFscRipTloN Odor Intdn wivroclr etc ft 0 4.Date Well(s)Completed: �r Well ID# ft a t: a 5a.Well�'O on: ft �-d & Sa ,Jr�(0`� Lo� 4 �� S--d ft. 30 ft• ran, Facility/Owner Name Facility ID#(if applicable) ft. ft. *,•1� l.+ (903 S chi V S fL ft. Physical Address,City,and Zip ft. ft Fro f� L County Parcel Identification No.(PEN) e e ( e r\ ;t 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one lat(long is sufficient) 22.Certification: N W / - D- 6.h(are)the well(s): ermaneat or ❑Temporary Signature of Certified Well Contractor Date By signing this form,I hereby cerdfy that the wil(s)was(were)constructed in accordance with 7.Is this a repair to an existing well: ❑Yes or MNo 1 SA NCAC 02C.0100 or 15A 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 ( 'See Over'in Remarks Box).You may also attach additional pages if necessary. drilled' 24.SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: 3 G (fL) For multiple wells list all depths ifdifferent(example-3@200'and 2@100 Submit this GW-1 within 30 days of well completion per the following: 10.Static water level below top of casing: V ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR), lfwuter level is above casing,use"+;' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 11.Borehole diameter: (�D (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC) Program,1636 MSC,Raleigh,NC 27699-1636 IL Well construction method: P10 40 r` (i e.auger,rotary,cable,direct push etc.)-�/ 24c-For Water Supply and Open-Loop Geothermal Return Wells Copy to the county envtronmenta ea th department of the county where installed FOR WATER SUPPLY WELLS ONLY: ) 24d.For Water Wells roducm over 100,000 GPD:Copy to DWR,CCPCUA 13a.Yield(gpm) 91 Method of best: (i31 a L / Permit Program,1611 MSC,Raleigh,NC 27699-1611 13b.Disinfection type: 1 Amount: /b Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2019