GW1-2021-05476_Well Construction - GW1_20210722

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only
1.Well Contractor Information: d
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Well Contractor Name FROM TO DFSCRIPiTON
& ft.
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NC Well Contractor Certification Number _
FROM TO DIAME THICKNESS MATERIALR
Company Name c ft d ft 6 1
2.Well Construction Permit#: 1 0' 0 d .l a FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(1.e.UIC,County,State,Variance,etc.) in.
3:Well Use(check well use): ft ft is
Water Supply Well: FROM TO DIAMETER SLOT SUE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. fL in.
Industrial/Commercial DResidential Water Supply(shard)
irrigation FROM TO KATERIAL EMPLACEMENT METHOD&AMOUNT
Non-water Supply Well: d ft, dw t1 e c&-e IS. S b
Monitoring DRecovery ft. ft � pl(�
Injection Well: ft. ft.Aquifer Recharge 13Groundwater Remediation _
Aquifer Storage and Recovery 13 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13 Stormwater Drainage ft. %
Experimental Technology 13Subsidence Control ft• ft-
Geothermal(Closed Loop) Tracer
Geothermal(H ling Return) 0Other lain under#21 Remarks FROM TO DESCRIP77ON color,harda sail/rock type,grain size,etc
1 r ft' �IC�Jrb C'
4.Date Well(s)Completed: Z t 2- Well # ft. tt
ID ,
5a,Well Location: R S Z
0 ft.. Q ft. t^c�-►�.+ei :`„`� arty
Facility/Owner Name /^ Facility ID#(if applicable) • ft. i� ' " '
cD
Physical Address,City,and Zip fi' D'
County Parcel identification No..(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(S)
Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of thisfiorm.
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.
dried: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (fL) 24a. For AD Wells: Submit this form within 30 days of completion of well
For multiple wells list an depths if d jfferent(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection 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,EUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) IR 0 Method of test: r 24c.For Water Supply&Injection Wells: In addition to sending the form to
++'' ,f the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: iV i I Amount: ' tr Z completion of well construction 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