GW1-2021-07078_Well Construction - GW1_20210915

WELL CONSTRUCTION RECORD(GW-1) For tntemal Use Only:
�1.\Well Contractor Information: r N e
F/�/S�'1 J1 L��C11(n)0�Tl \" ° .., -;�14.-'WATER`ZONES.
Mtom TO DESCRIPTION
well Comma"Nam SEP 15 2021 y4o
NC Well Contractor Certification Number 1t�0i1:,3v� `�QY�10� OMj1TE1t.CING;�rm'
MAffitW
Ua
fro -E- ft 2 Z TO
is
Com6ny Name
1CIMNSRGASIxG?;OR 1UliINGr
2.Well Construction Permit i{: Z I FROM TO D14MLTM f MAURIAL
List all applicable well construction permits(ie.UIC,County,State,Variance,etc.)
ft ft in.
ft. ft. tD'
3.Well Use(check well use):
[industWCommercial
supply well: FROM To DIAME[Fdt` s%oT slz� ifficlss MATPdtiAl
cultural 13Mttnicipal/Public 0 ft. ft in.
thermal(Heming/Cooling Supply) Residential Water Supply(single) ft ft. in.
Residential Water Supply(shared)on FROM TO MATERIAL EAIPLACIIIIIFdVT METHOD&AMOUNT
Non-Water Supply Well: v ft ft Hole
Roo bur-
flMonitoring Recovery fL ft
lGeothermal
ection Well: fc. ft.
quifer Recharge ®Groundwater Remediation --
quifer Storage and Recovery Salinity Barrier `FROSAND7GI TO PACK MAIL 'EMPI.ncEmnwr NWMOD
quifer Test E)Stormwater Drainage fL ft.
xperimental Technology Subsidence Control ft. fL
eothermal(Closed Loop) Tracer 20.DRILLING LOG:ittietiadditidcalslieeta R.
(Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCREMON color,tuuaaen,soiUreek cM
rc 2 fL $and
4.Date Well(s)Completed: �2-� Well HW 2 fL 2 tt. s 104C
5a.Well Locatiog 2 ft �� 6 ran
T� L �Q5 Q k. ft.
Facility/Owner Name pp 1� Facility ID#(ifapplicable) fL ft.files- 6 Ck(OC,L mod., 4(,nr1 `G fL ff.
(Physical Address,City,and Zip ft. ft.
W I (So MREMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one hit/long is sufficient) 22.Certification:
N W t�
(
6.Is(are)the well(s)aPermanent or OTemporary Signiture of Certified Well Contractor Efate
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or vgNo with ISA 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.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 I 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: l v J (fk) 24a. For AO 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: 22 J5 (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: //�� (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12 Well construction method: 1�0 f'�G'l� above,also submit one copy of this;"form within 30 days of completion of well
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
i
13s.Yield(gpm) 0 Method of test: 0 24c.For Water Supply&Iniettiou Wells: 'In addition to sending the form to
p the,address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: Amount LB completion of well construction to they 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