GW1-2021-02266_Well Construction - GW1_20210615

Y
WELL CONSTRUCTION RECORD(GW-1). For Internal Use Only:
1.Well Con trae yr,
on: 1
�j 14:wATERZONES
Well Contractor Name �1� JFROM TO DESCRUMON
1 fLfL'7� J J 1 nc3.03 j '1 R fL
NC Well Contractor Number ?rOC IS OUTER,CASING for.mdltimsed OR LINER rt'a
�s , a J(('j', � v�v�r✓�)dn FROM TO DIAMETER I THICKNESS MATERIAL
i fL " is C
Company Name / 16:.1PINER.... G OR:TUBINC tksmel.
2.Well Construction Permit#: f��6 FROM I TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits li.e.UIC.County,State,Variance,etc.) fL fL in.
3.Well Use(check well use): R 1°
Water Supply Well: 'I7'.SCREEN' ..
FROM TO DIAMETER I SLDTSLZE I THICKNESS I MATERIAL
Agricultural QMunt blic 0 & '�Yft- Lit in ), �L
Geothermal(Heating/Cooling Supply) idential Water Supply(single) fL / th 1
IndustriaUCommercial 13Residential Water Supply(shared)
Irrigation FROM I TO MATERIAL EMPLACE ENT METH D&AMOUNT
Non-Water Supply Well: fL p� Cow
rJ
Monitoring Recovery ft. fL
Injection Wen:
fL ft.
Aquifer Recharge Groundwater Remediation 19:.SAND/GRAVEL°PIS(K"id &b
Aquifer Storage and Recovery Salinity Barrier FROM TO TERIAL I EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage fc �
Experimental Technology 13Subsidence Control &
Geothermal(Closed Loop) ®Tracer i8 DRiLf ING',1DG,attach addiflanat&beeeif
Geothermal Hearin Conlin Return) Other lain under 921 Remarks FROM DESCRU113ON color,hardness,soilt o k type,grain sine,etc
YfL
4.Date Well(s)Completed: Well ID# ly ft 13r fc
5a.Well Location: k' &
s ; /T ., fL &
Facility/Owner Name Facility M#(if applicable) fL fL
®zl S�O/1 e� fL fL
Physi .City,and Tap +�► +fL
ft
.S ZL:REMARKS '
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lavlong is sufficient) 22.Certification:
W � .
6.Is(are)the wells) Permanent or Tempo;No
Signature of C 5 eContractor pare
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or with ISA 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 ofthis record has been provided to the well owner.
repair under 921 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-I 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: �3� 00 24a. For All Wens: Submit this form within 30 days of completion of well
For multiple wells list all depths ff drfferent(example-3Q200'and 2@ 100 1 construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use'++' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. y (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: �2J above,also submit one copy of this form within 30 days of completion of well
(ire.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
r
L13aYield(gpm) © Method of test, a 24c.For Water Suoniv&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
sinfection type: Amount: OS 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