GW1-2021-00195_Well Construction - GW1_20210505

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WELL CONSTRUCTION RECORD(GW-1) For lnumal use only:
1.Well Contractor Information: -
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L1n ►Z. sle-el. ���Q" y�..� ' 14.WATER ZONES
Well Contract ame FROM TO DESCRIMON
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NC Well Contractor Certification Number
ref= 15.OUTER CASING for multi eased wens OR LINM da ble
�� s,.,,, ' ��'t;o�� FROM TO DIAINEIEB ZffiCE43
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CompanY Nam 16 CASING OR T[JBING thermal
2.Well Construction Permit#: 33 3 3 FROM TO I DIAMETER I TfficEIMS MATIMIAL
List all applicable we0 construcoon permits(te.UIC.Cormty,Smote.Variance.etc) ft. & I m
3.Well Use(check well use): ft ft in.
Water Supply Well: F
ROM To
To D1AMrTER S.oT SME '181CRXESs MATERIAL
Agicultmal QMunicipal&tiblic tt in.
Geothermal(Heating/Cooliog Supply) Residential Water Sttpply(single) ID
Industrial/Commercial Residential Water Supply(shared)
Irri •un TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 3 fL E eAe i
nvMunrtonng QReoovery Injection wen: &
Aquifer Recharge [)Grotmdwatu Remediarion
19.SAND/GRAVEL PACK d ble
quifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I MPLACOUXT METHOn
3Aquifer Test DStotmwater Drainage & 1t
Experimental Technology DSubsideoce Control ft. fL
Geothermal(Closed Loop) DTracaa 20.DRUXING LOG Latlach additional sheets ff neeessa
Geothamal(Heating/Cooling Return) FlOther(explain under#21 Remarks) FROM TO DFSCRIMON color,hardness,ssBrrsea type,grain she,etc
Q 1t I I rno i sf red 95C
4.Date Well(s)Completed: A(- O Weil ID# 33 33 7.1. 16' ft' —jS' ft r0 ` Govfo-el Qe
Sa.Well Location: 75r ft M ft• Sall-{ r �*�
Facility/Owner Name Facility ID#(if applicable) R ft'
JAg 01A- JIL ft.
Phystad Address,City.and Zip & R.
Y a)n c'�, 0 4 z—► o�J o 0 9 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutestseconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3 b . 1-7 G11 N 1 $• 3© Ak`1 w —f . e r 04 a I
6.Is(are)the well(s)oPermanent or Temporary Signature of C&ufied Welf Contractor Date
By signing this form,I hereby cenyy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or [allo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,full out brawn well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under#21 rennarks section or on the back ofiks 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,onlyi 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction Mails. You may also attach additional pages if necessary.
drilled 1 SURMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 `T (D-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list aAdepths if different(esnmple-3®200'and 2@100) construction to the following:
10.Static water level below top.of txshrg: 3 (tt.) Division of Water Resources,Information Proemsing Unit,
Ifwater level is above swing,ace"+n 1617 Man Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. ,b Q-) 24b.For Infection Wells: In addition to sending the form to the address in 24a
�0 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 14l 9, construction to the following:
(i.e.auger,rotary.cable,direct push,etc.)
Division of Water Resonrces,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) Method of test:�_l_-�_ 241---For Water Supply&Infection 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 typ�- �(�i Amount: ® 01— completion of well construction to the county health department of the county
where constructed
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Form GW-1 North Carolina Department of Fuvironmental Quality-Division of Water Resources Revised 2-22-2016