GW1-2021-00284_Well Construction - GW1_20210125

WELL CONSTRUCTION RECORD(GW-1) For Internal use Only:
1.Well Contractor Information:
F�t bit M WATER ZONES
Well Contmdor Name FROM TO DERCRlrMN
19�ft- A 10
3514 1 IL ft.
NC,,Well Contractor Certification Numbs 11 OUTER CASING Oftehir multi used wells OR LMER a ble
y( i I``I vie i n P. oM To D Tic s Mn
Company Name 16.UR41M CASING OR T[IBIN tbermal dried
2.Well Construction Permit#: FROM TO DIAMBTSR I MUCE74:ss MATF3i+1
List all applicable weU construction permits(Le.UIC,Cmady,fie.Variance.etc.) ft ft. I°
3.Well Use(check well on): M It m
Water Supply17 sCREErI
Well: FROM TO DIAMETER SLOTSM 'ffiCEMM MATERML
Agricultural QMunicipaUPublic U tt M In.
Geothermal(Hea WCooling Supply) EIResidesituil Water Supply(single) It It
lndustrial/Commercial DResidential Water Supply(shared) M GROUT
•ou FROM TO MATEMML', Fd1D'LACIM"D "Mole&AMOu"
Non-Water Supply Well: Tf^-^-�� ft ft uYh
Monitoring I�R-covmy ft aQ ft tll. a-V
Injection wen: -
tt n.
Wd
DAquifw Recharge Groundwater Remteliation
l9:SAND/GRAVEL PACK bb:
:]Aquifer Storage and Recovery OSalinily Barth FROM I TO I MATKRIAL EMn ACP HXTML-M0D
Aquifer Test [:JStormwater Drainage L I ft"
Experimental Technology [3Subsideme Control ft-
Geothermal(Closed loop) Tracer 2R DRILLING LOG attaeb additional if
FROM TO DESCRIMON rabr,hadwas,saWrodc etc
Geothermal(Heating/Cooling Return) __ Othex(explain under#21 Remarks) �
fr. It D 2 d a I
4.Date Well(s)Completed: 1 J Well ID# I (A 21- ft- s ft /bid ti S e r J Etc
Sa.Well Location: 7S-ft- tt.
1, M &
Facility/Owner Name Facility 1139(ff applicable) ft ft
�V`rela
Fhysieal Address,Oi ,and Zip ft ft
2L REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreestminatestseconds or decimal degrees:
(if well field,one Wong is sufficient). 22.Certification:
3L. 66. N -NS I"a 3'Ao W ` 91 .� 1
6.Is(are)the weQ(s) Permanent or Temporary »o Cahfi ll Con 1 Dare
By signing this form,I hereby certify that the weU(s)was(were)constructed in accordance
7.Is this a repair town existing well: OYes or [,No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
o this record has been provided to the well owner.
If this is a repair,fill out bnown weU construction information and explain the nature of flu �`)rO�'f
repair wider#21 remarks section or on the back ofthis form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells`it�a—41ie same You may use the back of this page'to provide additional well site details or well
construction,onlX 1 GW-1 is needed Indicate TOTAL NUMBER of webs 10T on details. You may also attach additional pages if necessary.
drilled r N `�a
;,�SUB�TTAL INSTRUCTIONS
9.Total well depth below land surface: a oZ 5 (ft.),;r;j4a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffererd(exanpk-3Q200'and 2(a)1t7�, ';: : construction to the following.-
�i• V
10.Static water level below top of casing: oZ d (fL) Division of Water Resources,Information Processing Unit,
lf'water level is above casing,use"+" 1617 Maul Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter. pprm-) 24h.For Infection Wens: In addition to sending the form to the address in 24a
1�®Ti (�� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 41
construction to the following:
(Le.auger,rotary,cable,direct push,etc-)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 1 24c.For Water SnPuly&Injection WA-- 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: e Amount: 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 Fnvironmental Quality-Division of Water Resources Revised 2-22 2016
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