GW1-2021-02264_Well Construction - GW1_20210512

' xttl' `FOfl=1i
WELL CONSTRUCTION RECORD(GW-11. For Internal Use Only:
1.Well Contrae r Information:
14 WATER ZONES..
70 ESCReTIO
Well Cormaaor Name FROM D N
R Oft.
2oC 2 & f`
NC Well Contract7C **on Number Ili.OUTER:CASING. for multi-coed wens'OR>LINER fFROM TO DIAMETER KN
THICESS MATERIAL
flu & in V
Compatry Name r — i
n w 16 aINN$R. ' GrOR.TiIBING, th�mal:d
2.Well Construction Permit#: �� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,i/ariance,eta) R fr 1 L
3.Well Use(check well rise): fr fL 1O
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13MurficipatbPublic 0 ft. . S in.
Geothermal(Heating/Cooling Supply) idential Water Supply(single) fL ft. ;o
Industrial/Commercial -Residential Water Supply(shared)
a18:GROUT ,
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: & C5 It.
Monitoring Recovery & &
Injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation
19..SAND/GRtYVE$'PACH i .
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage R fL
Experimental Technology [.Subsidence Control fL ft.
Geothermal(Closed Loop) Tracer 28 DRILL II. LG..a#w' :zdditienetsbbeftif'
Geothermal (Heating/Cooling Return) nOther(explain under#21 Remarks FROM I TO DESCRIPTION color,narmes%sm1frock sme etc
4.Date Well(s)Completed: Well ID# pv flu
a
5a.Well Location: fL &
Facility/Owner Name Facility ID#(if applicable) R' ft
ft. ft RECEIVED
Physical City,and 'p
ft ft
2L:REMARKS
�� Inforr^at rl (�County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 4
D VR 5e,^vorT
(ifwell field,one tat/long is sufficient) 22.Certification:
W i
2 /I
6.Is(are)the weil(s) Permanent or OTemporary Signature ofCcaed Well Contractor Daze
� 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: ®Yes or IG3"" with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,iU out known well construction information and explain the nature of the copy of this 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-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: 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dorereru(example-Jg200 and 2@1001 construction to the following:
10.Static water level below top of casing: S— (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. V (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
T D
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 posh,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test 24c. For Water Supply&Iniection Wells: in addition to sending the form to
/ r the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: t`7 T�� Amount: �I 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