GW1-2021-06345_Well Construction - GW1_20210915

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information: f
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PROM TO DESCRIPTION
Well Contractor Name ft. ft.
a ? 6�~/-� AR n^�
NC Well Contractor Certification Number :,LS.'OUTER.CASING'tor•ntuts*rc"dwelt OA;1sINRR d '' 7s1e
�o FROM TO DIAMEI'Fla ;. THICKINESS
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Company Name Y6 INNER EASING OR-3{IBI11G r<
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2.Well Construction Permit#: W •- FROM TO DIAMElFdt� � in.List all applicable well construction permits Ae.UIC,County.State,Variance,eic.)
ft, ft W.
3.Well Use(check well use):
,,:M SCREEN
Water Supply Well: FROM TO I DIAMETER I SLOT SIZE I THICKNESS MATFdWL"„
cultural [3M 'cipal/Public 0 & ft in.
Geothermal(Heating/Cooling Supply) 13Residential Water Supply(single) &
Industrial/CommercialResidential Water Supply(shared) i8 GROLII _
irrigation FROM TO:l MATERIAL... " EMPLACEMENT D OD&AMOUNT
Non-Water Supply Well: 0 ft Q ft. P Nr P
Monitoring pRecovery ft. ft
Injection Well: ft ft.
Aquifer Recharge Groundwater Remediation
"I9 SAND/GRAVEI:'PACK d " ea31e
Aquifer Storage and Recovery 13Salmity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage & fL
Experimental Technology Subsidence Control fL ft
Geothermal(Closed Loop) Tracer 20.DRl AJNG LOG;attach sddt6oniil:stieets ld"" :Fa.
Geothermal eaten Cooling Return _ Other(e lain under#21 Remarks) FROM To nEsclt>prTorrG color,Oe.r�ea saa/reek eta
4.Date Well(s)Completed: ` Well ID# fi' aQ R
58.Well Location: D R Q�ft fOp J
C � V C o l I n S ft.
Facility/Owner Name Facility ID#(i€applicable) ft' ft
a� II t a �1,� 14 ►e ft. ft.
L�i � r\ `/ I V ! �9rn/'.f?`•r7ir ri 1Zl
Physical ,and fL ft ;°Oil'3i Uri ^.i B
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2L REMARKS
County—� Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 11
(ifwell field,one lavlong is sufficient) 22.Certification:
N W Rzd
6.Is(are)the weil(s)J!(Permanent or 13Temporary Signature of citified Well Co for Date'
By signing this form,1 hereby terrify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or [3No with 15A NCAC 02C.0100 or 15A NCAC 02C.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#21 remarks section or on the back of this form.
23.5ite 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: _ G LI (fk) 24a. For Ali Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200 and 2@100') construction to the following:
10.Static water level below top of casing: t� (ft) Division of Water Resources,Information Processing Unit,!f water[eve!is above casing,use^+ 1617 Mail Service Center,Raleigh,NC 276"-1617
11.Borehole diameter: l0 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: A d4 Q r t/ above,also submit one copy of this form within 30 days of completion of well
(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 276"-1636
13a.Yield(gpm) Method of test: 24c.For Water Suouly&Infection Wells: In addition to sending the form to
1 t �� 1 1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: I 1 1 Amount 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