GW1-2021-01855_Well Construction - GW1_20210503

WELL CONSTRUCTION RECORD(GW-1). For Intemal Use Only:
1.Well Contrac of don-
14 WATER ZONES .
FROM TO DESCRIPTION
Well Contactor Name
V fL fL
NC Well Contractor Certificad 1S,
r OUTER: mSDi nDtiAMw
EE MOMS— TERALFROM TO
I ft in
Company Name
1(c.l[NNRRCASM.U1t.......TIJBiNc. !laud-Ion
2.Well Construction Permit#: / 7�ft-
-Ugiricult:unil DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. IC,County,State,Variance,etc.) 44 in
3.Well Use(check well use): & in.
Water Supply Well: EN'
TO DIAMETER SLOTSIZE THICKNESS MATERIAL
®M pal/Public ft is
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) in
IndustriaUCommercial Residential Water Supply(shared)
18..GROl1T
-)Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fLft
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge ®Groundwater Remediation
19.:SAND/GRAV3iL'PACK tifariniicatki
Aquifer Storage and Recovery ®Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage fc ft.
Experimental Technology OSubsidence Control ft.
Geothermal(Closed Loop) 13Tracer 38 DRII I gYG:LOG..madr:ad&fieaW slceeis f -
FROM TO DFSCRwn color,lvutlness,soilt.ock size,etc
lCreothermal(Heatirr Cool' ) Other(explain under#21 Remarks ft- I r fL L±
4.Date Well(s)Completed: J a Well ID# ft D & b
5a.Well cation: ft. R
Facility/l)wnccr Names // F ility M#(�if+app/livable) fr f r: e
Y � b Gxo"' �, I c�Glq� � ft. ft .._
Physical tens,City,and Zip ft. & MAY
2L:REMARKB . ;.
Coumy Parcel Identification No.(PIN) Information ormation Processinn Unit
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: L DI"M Section
(if well field,ace lat/long is sufficient) 22.Certification:
W
6.Is(are)the wells) Permanent or Temporary Signature of Certified Well Contrast Date
/ By stgning this form certify,I hereby cert that the well(s)was(were)consbucted in accordance
7.Is this a repair to an existing well: ®Yes or wl o� J with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
1f this is a repair,fill out brown well construction information and explain the nature of the copy of thts record has been provided to the well owner.
repair under 021 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' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (L) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths#Afferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 1/O YL) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: O
above,also submit one copy of this form within 30 days of completion of well
�r L(i.e.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
I
13a.Yield(gpm) b Method of test 24c.For Water Supply&Infection 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: °1 Amount: 4V-12b completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016