GW1-2021-06841_Well Construction - GW1_20210419

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
_ 1.Wei Contractor Informq:
14s•WA1 ;7.UNES.
FROM TO DESCR
Well Contra D'TIQi
ft ft.
NC Wel1C ntractor�CfertificcaationN
FttOMUTER'. SING.'foc;mtilti TERM ORCKTHICKNESS I MATERIAL
Company Name
`16 IlVNER'CASING.OIt:Ti98ING- eotbei m3Le`ibsMiloo
2.Well Construction Permit#: l/!/��J J FROM TO DIAMETER THICKNESS I MATERIAL -
List all applicable well construction permits 0.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): fa IL in.
Water Supply Well: 17;SCREENFROM TO � DIAMETER- SLOT SIZE THICKNFSS I MATERIAL
Agricultural ®MunicipaUPublic U ft. ft. in
Geothermal(fieating/Cooling Supply) OResidential Water Supply(single) ft. &
_ IndustriaUCommercial DResidential Water Supply(shared)
1>IGRODT ,
ation FROM To.., MATERIAL .EMPILACEMENT MUMOD AMOUNT
Non-Water Supply Well: d & ft.
;Monitoring _:Recovery ft ft.
Injection Well: 406,
ft. ft.
Aquifer Recharge DGroundwaterikernediation
79 SAND/GRi1VEL RACK :a linable
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLA(EMENTMETHOD
Aquifer Test E)Stormwater Drainage ft. & 1
Experimental Technology [3Subsidence Control . fL ft.
Geothermal(Closed Loop) OTracer i:2MbRELUWGIOG`attaefiaddstionaL"sLa it
Geothermal eating(Cooling Return) :Other(explain under#21 Remarks) FROM TO D ON color hodmp soiUmek err ,
It, .71 ay
ft. i�LABA
4.Date Welt(s)Completed: 4e11ID# 1 fa 33fL
Sa.Well Location: ..
ft. 4v ft..
he-L P®��r oft ft
Facility/Owner Name VFacility f applicable) ft. ft.
Phy i t �djdress,City,and Zip
I, ft.
21.AEMARM
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweefll field,one lat/long is sufficient) _,�^ 22.Cc cation: ? I
6.Is(are)the wells) anent or Temporary ignatnre of ad Well Contractor Date
11��� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
Imo
7.Is this a repair to an existing well: 0 Yes or "" with 15A NCAC 02C.0I00 or ISA NCAC 02C.02W Welf Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copyofthis recant 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,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: DD (fW Us.For All Welts: Submit this,form within 30 days of completion of well
For multiple wells list all depths ifdi.(ferent(example-3@200'and 2@10" CAMstiMC1011 to the f011owing:
10.Static water level below top of casing: 02 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"t^ 1617 Mail Service Center,Ralef h,NC 27699-1617
11.Borehole diameter: [/Si (in.) 24b.For Infection 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: Alt construction to the following:
(i.e.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) ZV Method oftest:�� �� 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: Amount: � °G 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