GW1-2021-03458_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1. Contractor Information: D
RECEN
sc e 14.NA7ER7Alv1s
Well Contractor 5me tLvlOhf TO DESCRIPTION
2ND 3 i D ft. ft.
prccesging U rt. rt.
NC y'a1I Co7elol Certitication Number �I1fOfI�''ap���{�. j10f1
/�,1� ��� l LJS� .JS_OUTER CASING formatti cases yells"OR:L7N7 R-Ira licsbte
Ip/V lJ t A,/ �1FROM 1'ODIANIMrFR I'HnICnss5 MA'I'MRIAI1/ [ ft. ft. / _ in. 5De2_ C_
Company Name 1SJ -
. ����� _ FROM ERCA�SINCUR FlFB1AM 'cothcrmaTc)osctNESS,�
2.Well Construction Permit#' '/l_-f//l/'t FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(t.e.UIC.County.,Stat�mce.etc.) ft. ft. in.
3.Well Use(check well use): ft. R. in,
Water Supply Well: FRonrREL TO DIAMETER' ,SLOT SIZE THICKNESS MATERT4L
Agricultural Mun cipal/Public ft. ft. in!
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) in:
_.industrial/Commercial Residential Water Supply(shared) 1g,GROUT .'i
Irrigation FROM TO MATERIAL FMPLACEMENT METHOD&AalOUNT
Nun-Water Supply Well: ft 3 ft.
Monitoring DRecovery 3 ft. v ft.
Injection Well:
ft ft.
Aquifer Recharge Groundwater Remediation _
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStom)water Drainage ft ft.
Experimental Technology Subsidence Control ft. ft.
i
Geothermal(Closed Loop) Tracer 20.-DR1LLIIVG LOG attach addititi il.sheefs:ffnecessa
FROM TO DESCRIPTION color,hardness,soiVrock c, in size,etc.
Geothermal(HeatinfJCooliug Return) Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: Well ID# $ ft. ft.
r L
5a.Well Location: 0 ft-
2 20 ft-
ft. ft.
Facin/lity/Owne/rn.Nu� d"Faty ID#(it rt. ft.
applicable) 1�
,2g- //foi.li, ! D�br, l VC.J fL fL
Ph l Addr s,City,and Zip
ft. ft
'LREMARKS 3.. ... r. -
ra ayn
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
rf well field,one is sufficient)(� lat/lon g b ) 22.Certification:
. 50 1 N U 3 0 . 5/7/I W mtylf
I 5
6.Is(are)the wells) Permanent or OTemporary Signature oft ified Well Contractor Date
By signing this Ibrnt,I hereby certih,that the wells)was(were)corutrucied in accordance
7.Is this a repair to an existing well: c3 Yes or 9-- with 15.4 NCAC 02C.0100 or 15A NCAC 02C.02U0 Well Construction Standards and that a
Ifthis is a nEmir,ill out known well construction information and atplain the nature of the co1n,of this record has been provided to the hell owner.
repair under#21 remarks section or an the bark of this./brin.
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I
I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ,220 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiJferent(example-3(a�200'and 2(a!0(I') construction to the following:
t
10.Static water level below top of casing: (ft.) Division of Water Res o urees,information Processing Unit,
If water level is above rasing,use.•+- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: LO (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
12.Well construction method: 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: 1636 Mail Service lCenter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 1'Y 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: I Amount: cup completion of well construction to.the county health department of the county
where constructed.
Fom)G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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