GW1-2021-05478_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Informa on: RAO
ra a �J 14.WATER ZONES
Well Contractor Nime J Do FROM TO DESCRIPTION
JULft. ��� ft. 2 i ;a��•VIA hn(n
_y 3ti011 hrpf ESSIIIf� ft ft.
NC Well Contractor Certification Number Ihalm' tr r;;C11
/y /'pi;V t<Se 15.OUTER CASING for mul&cased wells OKLINER If licable
Ara AT E 6 614 W t11 � PIA M� t y�. FROM TO DIAMETER THICKNESS MATERIAL
Company Nam ^ �(/ Q 0 ft. ft. G ! in. -6 g 141V.
L� OO D V q Q O 16.INNER CASING OR TUBING eothermatclosed
2.Well Construction Permit#: ff 1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(l.e. UIC,County,State, Variance,etc.) 0 ft. I 0 ft. q in. V
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural unicipal/Public
Geothermal(Heating/Cooling Supply) SaRmidritial Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
1ni ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: b ft. a tt. Irflod rqq t
Monitoring DRecovery ft. ft
Injection Well:
Aquifer Recharge nGroundwater Remediation
Ami 19.:SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test C)Stormwater Drainage it R•
Experimental Technology OSubsidence Control ft, I ft.
Geothermal(Closed Loop) OTracer 20.DRILLING.LOG attach additional sheets if necessary)
FROM I TO DESCRIPTION ftolop hardness,soiltrock type,grain size,etc
Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) Ia ft. 1 ft. i
4.Date Well(s)Completed: — 3- Well ID# a ft. kilt
Sa.Well Location: U iL p n r a C'k
l!� I I e v. oft. 00 ft. ro-t
Facility/Owner Name Facility ID#(if applicable) ft ft.
d f 9 Drtverf 4vJ1y)A oalw► rd ft I f`
Physical Address,City,and Zip Z t' O'Oh �,154 � ft. ft
All�I a J Yl X REMARKS UU
County Parcel Identification No.(PIN) Y% I I Q O
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat(long is sufficient) 22.Cerd tion:
N w —! 19
6.Is(are)the well(s)6ermanent or Temporary Signature of Certified ell Contractor Date G
By signing this form,I hereby certify that the we11(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or �No with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
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 SUBMITTAL INSTRUCTIONS!
9.Total well depth below land surface: 3 0 (ft•) 24a. For All Wells: Submit thi's form within 30 days of completion of well
For multiple wells list all depths if d fferent(example-3©200'and 2@100) 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 Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: r-6 tQ 1^p
above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary, petc.) construction to the following:
' ug tary,cable,direct push, i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) '2— Method of test: 24c.For Water Suonly&Iniectlon 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: l� Amount: b• completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource` Revised 2-22-2016