GW1-2021-03240_Well Construction - GW1_20210628

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
FROM TO DESCRIPTION
Well Contractor Name tt ft.
6213 A ft. ft. I �
NC Wcll C tractor Certification Nu ber
/qq� I f //�/ 'I&.0 TLLt.CASIN formulti=.caaedwels OR7sDVEA:IEa llee6le
/ /1 p /� 1/ / "si /n/�, FROM TO DDIAME'TE�Rr-�I THICKNESS MAyT�ERIAL
Company Name 1.�[ iti ��J iri' tr ft. q ft. tP t 1) n' /`� /� e
���� ' `_� ���� ,A6:INNER CASWG.UR ,USING.'cotter l qo
2.Well Construction Permit#• �1 FROM 'f0 M DIARTF:R I THICKNESS I MATI:RIAI.
List all applicable well construction perwits(i.e.UIC,CouncV.State,Variance,etc.) ft. ft. Ins
3.Well Use(check well use): ft. ft. in,
Water Supply Well: 14JSCREEN:.
FROM I TO I DIAMETER SLOT SIZE I THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) tt• tt. I In, i
Industrial/Commercial DResidcntial Water Supply(shared) 18,.GROUT
Irrigation FROM I TO MATERIAL i EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft. b 5
Monitoring 13itecovery ft. ft.
Injection well:
ft. ft.
Aquifer Recharge QGroundwater Remediation 19.9AND/GRAVEL PACK Ifs 'Iteable `
Aquifer Storage and Recovery 13Salinity Barrier' FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13StormwaterDrainage tt• ft.
Experimental Techno log y Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 2O.'DRILL .G LOGt attach addltiouAhslitett It aecess'e :. .:
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks FROM TO DESCRIPTION color.6ardoeaa aolFrock i e taro size eke.
4.Date Well(s)Completed: "�( Well ID# D tt. ft. y^QIU I l e
So.Well Location: ft. ft.
Dbr15 5i�m0 n064
Facility/Owner Name Facility IDil(ifapplicablc) tt tt I
Physical ddr"s,_City,an Zip ft. ff.
e,at I�\�� 21,REMARKS. l
County '�"' Parcel Identification No.(PIN) �� SeC'(°Orl
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,
' one lat/long is sufficient) �7 22.Ce cation: i
6.Is(are)the well(s)ol(.rmanent or 13Temporary Signature of Certified Well Contractr I Date
By signing this form,1 herebv cei76 that the well(s)was(were)constructed In accwddmrce
7.Is this a repair to an existing well: OYes orft(No edit 15.4 NCAC 03C.0100 a•15.4 NCAC 01C.0100!Fell Constriction Standards and that a
If lbls is a repair,fill oat krroiin well construction hl/a mailon and explain the mitre of the copy of thhs t•ecard has been provided to the well owner.
repair under 1121 remarks section or on the back of this form.
23.Site diagram o1•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 necessaty.
drilled: /^ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 J (tt•) 24a. For All Wells: Submit this form within 30 days of completion of well
lior•multiple wells list all deplis►f drier enr(example-3@200'and 2Q100) construction to the following:
10..Static water level below top of casing: q 0 (ft.) Division of Water Resources,Information Processing Unit,
Iftwier level is above casing,use" " 1617 Mall Service Center Raleigh,NC 27699-1617
11.Borehole diameter: �A (in.) 24b.For Infection Wells: In ddition to sending the form to the address in 24a
12.Well construction method r �Y above,also submit one copy of this form within 30 days of completion of well
: construction to the following:
(i:e,auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: t 1636 Mail Service Center Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: CL I r 24c.For Water Sunniv&Intl tion 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: 0 r Amount: �.� completion of well constructiolt to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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