GW1-2021-01811_Well Construction - GW1_20210419

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VELL CONSTRUCTION RECORD(GW-1) For Internal Use only:
__�tWell Contractor Information: - -
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FROM TO DESCRIPTION
Well Contractor Name
.2a112 -
NC Well Contractor Certification Number 15 i0
1lTERCASQIG imnl�aeed went O1tI:HYER, f+a"' ble
FROM TO DIAMETER THICKNESS MATERIAL
.3 /d S J/ �J G J yL ft l s-- & J in
Company Name /, �L IfrINNER: C'CeYSING;O1t5TUBIBiG
2.Well Construction Permit#: AD )A �7 FROM TO DIAMETER THICK 14MS MATERIAL
ft. ft. in. V G
List all applicable well construction permits 0.e.WC,County,State,Variance,etc.) P
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO I DIAMETER SLOT SIZE I THICKNESS MATERIAL
Agricultural [3icipal/Public IL iG
Mtm in
Geothermal(Heating/Cooling Supply) [3 Residential Water Supply(single) fit tt is
htdustrial/Commercial DResidential Water Supply(Shared) l>k;fatOI1T ;z -
FROM TO MATER11" -EMPLACEMENT METHOD&AMOUNT
Mrffipt.on ff fL
Non-Water Supply Well: D
Monitoring 01tecovery ft ft
Injection Well: & iR
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery [3 Salinity Barrier FROM To JIL MATERML EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage
Experimental Technology ElSubsidence Control 11L ie
Geothemtal(Closed Loop) E3Tracer i2DRIIIGIAG athttialialredtalfecea -_ � s . . r ..
FROM TO :DESCREMON eobr,hard wWrwk ere.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks m / fL
AV
4.Date Well(s)Completed: 3- 3 d-Z/ Well ID# V A l f IL ,S�ft.
5a.Well Location: t/�-
%Ins-/v. ,-11Agxg! ILI
Facility/Owner ame n Facility ID#(if applicable) ft ft .
3 �o O q }�,�Ff !71/e L�haA7+7�e717/i A Cr L&LL) ft ft
a
Physical Ad"s,City,and Zip ft.
i5 11
County Parcel Identification No.(PIN) Y r J
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
•�:C;'i�i?YC� Y�n'1
(if well field,one lat/long is sufficient) 22.Certification:
N S o9 Jt� l.2 2 W L2 1/�'Ll
6.Is(are)the weil(s)G19- Dent or Temporary Si r t ue ofCat6e WeiLConRactar Date
By signing this form,I hereby certify'that the wells)was'(were)constructed in accordance
7.Is this a repair to an eilbst➢ng well: 0 Yes or [3No with MA NCAC 02C.01W or 1SA NCdC 02C.0100 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#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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: .2 ?r 00 24a.For All Wells: Submit this;form within 30 days of completion of well
For oadiTle wells list op depths#-different(arample-3@2200 and 2@1001 constriction to the following:
10.Static water level below top of casing: 3 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above using;we"+' 1617 Marl Savi©e Center,Raleftb,'NC 276991617
1 '
11.Borehole diameter: �ff (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
// above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: r r Y construction to the following:
(Le.auger,rotary,cable,direct push,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) �U Method of test: 4,r 24.For Water Suanly&Injection 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: 4 /o r,.a,e Amount: 42 Q 2 completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources h Revised 2-22-2016