GW1-2021-06331_Well Construction - GW1_20210915

WELL CONS1'RUCTION RECO
RD GW-1 For Internal Use Only:
1.Well Contractor Information:
't 14 WATER ZONES: `-,- i;
FROM TO DESCRlPf10N
Well Contractor Name ft &
NC Well Contractor Certification Number z fi•`�� 15,p()TgR.CASINGi for mattkeased vee9s UR7IINBR d
DIAMErER THICKNESS AIATERrAI
fL ft. ib /
Co Name //////���� \"(�' Q ,I&RMER CASINGSOR-TUBING' ilhikir", ._ '.
2.Well Construction Permit#:j G�W 1'7'1 mom TO DIAMEM! lac ss MAT�W
& in.
List all applicable weft construction permits(i.e.UIC,County,State,Variance,etc.)
3.Well Use(check well use): ft. fL in.
47.SCREEN
[Experimental
Supply Well: FROM TO DIAMKIER SLOT SM THICHNESS MATERIAL
cultural 13MunicipaVPublic 0 ft. & in.thermal(Heatmg/Cooling Supply) Residential Water Supply(single) fr fr in. ;strial/Commercial Residential Water Supply(shared) 18:GR ion FROM TO M1A EMPLACEMENT MnHOD&AMOUNT
Water Supply Well: D ft. f i e d /nitoring O Recovery fL ft.
ion Well: ft. fL
ifer Recharge Groundwater Remediation
.19.SANDIGRAVELPACK ira 'cableifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
ifer Test [3Stormwater Drainage D' fL
Technology Subsidence Control fL &
thermal(Closed Loop) Tracer 20.DRIId IIVG LOG'attieti additiowii sheets if' =;ithermal Heatin Cooling Return Other(explain under#21 Remarks) FROM TO DECCscR>pTlox rnbq hardness,soii/reek iae,an
4.Date Well(s)Completed: ell ID# & 110
ff 1 J
Sa Well Location: 2 D' 2 Lrfr. re
A A it. ft.
Facili /Owner Name f Facility ID#(if applicable) ft. ft.
z 14 c r o, ns K fL fL
Physical Address,City,and Zip R. fL
2LRE
County Parcel Identification No.(PIN) Y
kazk'5�01 Dow
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one lat/long is sufficient)
22.Certification:N W % z ne
6.Is(are)the well(s) Permanent or OTemporary ftnature ofCertifie ell gen6ftor Date
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 �No with 15A NCAC 02C.0100 or 15A NCAC 01C.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 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: ��� (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(�00'and 2@!00') construction to the following:
10.Static water level below top of casing: 36 (ft.) Division of Water Resources,Information Processing Unit,
lfwarer level is above casing,use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in) 1
�j ,, �-�) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: R 11,t {/ above,also submit one copy of this form within 30 days of completion of well
(i.c. construction to the following:
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
13s.Yield(gpm) 3 v Method of test: `aL� 24c.For Water Sunnly&Infection Wells: In addition to sending the form to
the address(es) above, also submit one I copy of this form within 30 days of
13b.Disinfection type: Amount: 4z completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Camlina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016