GW1-2021-03407_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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Well Contractor Name FROM TO DESCRIPTION
K�� ft. ft.
z V03 ft.
NC Well Contractor Certification Number 1�� x "
, J 15.LSUT7rR"CASt1NG foriiiniti-cased;�ceils Ai'tL7�'ER iE-e Iicgtite
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/� u�lt N'KOltl I'O UTANIN 1'RR '1'HICKNN;SS M.4'I'N KIAI
``�// §^ t ��,�����slr�� ft 8 ft. 6,Zs'in. SOk 2l PVC
Company Name �11�f SEfjon .:
Z — f sty, t4:11�NER CASING OR TlfB1nC' cothcrrou[ctoscd-Ieo"
2.Well Construction Permit#: �j 6`► FROM TO DIAMETER THICKNESS M TERIAL
List all applicable i ell construction permits(i.e.UIC,Count',State,Variance:etc.) ft• ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural 0Muuicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft. ft. in.
industrial/Commercial OResidential Water Supply(shared)
im ation FRONT I'O NIATVAIAL FMPI,ACRMENT I%IFI'HOD&ANIOUN'r'
Nun-Water Supply Well: 0 R. ft. 0� �� /00 .e
Monitoring DRecovery ft. 90 f" Eoa� vP
Injection Well: .0
ft. ft.
Aquifer Recharge []Groundwater Remediation
19:SAND/GRAVEL PACK if a )lit7
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACENIENT METHOD
Aquifer Test C)Stonnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) ElTracer 10 lb)RILIMA G10G atta_c_h additi6ii3tsheaisafirecessa';'s
Geothermal(Heating/Cooling Return) :Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soittrock e, in situ,etc.)ft So. ft.
4.Date Well(s)Completed:5—/0-2� Well iD# n. a.
ft. ft.
• 9160 slqSa.WellLo
D f'N fa P'
-rt WPM ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
m 0lJ
Physical Address,City,and Zip ft. ft.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell Yield,one Iat/long is sufficient) 22.Certification'
093` -VO, 035"
-S—�0
6.Is(are)the well(s) rmanent or Temporary Signature of Certified Well Contractor Date
Br signing this Ibrin,I herch- certi/i'that the svell(s)ivas(iverc)constructed in accordance
7.Is this a repair to an existing well: 13 Yes or W. rvith 15.4 NCAC 02C.01019 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair.fill out knout ivell construction infonnation and explain the nature ofthe copy ofihis record has been provided to the well owner.
repair under#21 remarks section or on the bark of this farm.
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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ?Q 0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(a200'and 2(a 100') construction to the following: i
10.Static water level below to of casing, /S O ft.
p g: ( ) Division of Water Resources,information Processing Unit,
If%vier level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form(within 30 days of completion of well
Well construction method: constriction to the following:
(i.e auger,rotary,cable,direct push,etc.).) k
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail ServicelCenter,Raleigh,NC 2 7699-1 63 6
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13a.Yield(gpm) -7l4 Method oftest• IiFI r 24c.For Water Supply&Iniection 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: Amount: C completion of Well construction to the county health department of the county
where constructed.
Fornt G W-I Noah Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016
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