GW1-2021-01990_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD(GW-b For Internal Use Only:
1.Well Contractor Information: II C
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FROM TO DESCRIPTION
Well Contractor Name It aL
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oL ft. ft.
NC Well Contractor Certification Number 15:O ING fornitlatedsse -
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ATERUL
W2�'��A�' W e l C o FROM TO rr. c Df,►1Y>ETER In. T>ftcxivFss tr O li
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Company Name 1&1NNWV—ASINfs'UR':7 UBING
2.Well Constriction Permit#
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List all applicable well construction permits rLe.UICC,ro ry,State,Variance,etc.) ft ft' :in
3.Well Use(check well use): ft ft.
Water Supply Well: '�17:�3CREEN._,. _,_ � .:��^� �'�._a�`�,t:""k•,.:: ,.. ... .�- ��. �. '
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. & in.
❑Geothermal(Heating/Cooling Supply) �idential Water Supply(single) ft. R, in.
❑IndustriaUCommercial ❑Residential Water Supply(shaved) ;r1volkoTTT r i'
❑lrri lion []Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT OD&AMOUNT
Non-Water Supply Well: d ft. P ft p r'.Q
❑Monitoring ❑Recovery ft ft
Injection Well: fG M
❑Aquifer Recharge ❑Groundwater Remediation
,t19';Sr1;19D(GRAY,EL°PAGIC° "."" qe
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERiAt EMPLACEhffiHrMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. fL
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer ;-2t1.DRII zsINGLOO,atticl'riddttien
❑Geothermal eating/Cooling Return ❑Other(explain under#21 Remark FROM TO DESCRIPTION color,huda soittrwir etc
Q G ft ft. osort
4.Date Well(s)Completed: v! Well EW ft. R `C Q
5a.Well Location: ft eft ft a h V' s. j - t V I
J
--re�j SPdr f c,*- CIOft• fit: % /,,.a 1% All t.
Facility/Ov6hr Name Facility ID#(if applicable) fL ft d
ft. ft. r^CCsB; Unit
Physical Addr6s,
LCity,and Zip ft ft
County Parcel Identification No.(PIN) C C ( /` C��# nr �S'a I'�►
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification: /J /
5.Islam)the well(s): APermanent or ❑Tempor'a_ry Signature of Certified well Contractor Date
By signing this form,I hereby certify that the well(s)wets(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ItNo I SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
tfthis is a repair,fill out brown well construction information and explain the nature of the 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:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only i GW-1 is needed. Indicate TOTAL NUMBER of wells ( 'See Over in Remarks Box).You may also attach additional pages if necessary.
filled' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: G (R•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@1001
10.Static water level below top of casing: O ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+I Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter V (in.) program,
For Injection Wells:Copy to DWR,Underground Injection Control JUQ
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: kG 40 Y
(Lc.auger,rotary,cable,direct push,etc.) 24c-For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county installed
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells vroduclne over 100,060 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 'v 1 Method of test: d Permit Program,1611 MSC,Raleigh;NC 27699-1611
13b.Disinfection type: 441 t-1 Amount:
Form GW-I , North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2018