GW1-2021-06993_Well Construction - GW1_20210510

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: e> _
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,14,WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 2021
PJI AY 1 /e e, ft. ,G fL 3 do
2 d f A fL ft.
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NC Well Contractor Certification Number '�•iC(i), t;vf1 Y.
/� J� 1_ 15:'.OUrER:CASING form' fi-eased ORLI .a NER ""livable
/J /^Cl S, y' C t FROM TO DLAMErER THICKNESS MATERIAL
ft. l�Z ft. 51 in. Z /
Company Name
r;:&TINNWCASING OR:T[TBING "eotheiiiiiil elwisid-loo
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2.Well Construction Permit#:1U -� / 6 FROM - TO DIAMETER I THICKNESS I MATERIAL,
List all applicable well construction permits(re.111C,County,State,Variance,etc.) M ft. An.
3.Well Use(check well use): fL M In.
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural OMunicipaUPublic 0 ft. ft. In.
Geothermal(Heating/Coolimg Supply) EIResidential Water Supply(single) ft is
Industrial/Commercial Residential Water Supply(shared)
tion - - FROM 170 .. MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft ft. e '/qv• , ".1
Monitoring DRecovey is ft b� s
Injection Well:
ft. fL
Aquifer Recharge ElGroundwater Remediation
A9:SAND/GRAVEI:PAGIC Ito IIeGble. ., �:,. :r ES.:::,•,:
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStonnwaterDminage ft, ft.
Experimental Technology OSubsidence Control ft R
Geothermal(Closed Loop) Tracer 20 DRIU- ING LOG a -additforia'Aiiits`Itri`"
Gcothertmal(Heating/Cooling Return) Other( FROM TO DESCRIPTION colo, - seWrock eta lain under#21 Remarks) R �
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4.Date Well(s)Completed:./"2 l Well ID# y fL y p tt
5a.Well Location: V41 fL Ya e, rL
;7e,// /I/L / L G ft. ft.
Facility/Owner Name / Facility ID##(ifapplicable) fL ft.
�yX,1L _.Odss �Fl��/lr l.,Ar�4� ./l�Gi �rZ)$ % fL
Physical
Address,Chitty,and Zip ft. ft.
2 /7 -3 3 k-�'S t21xRFMARK$: s,s 9 ,f.:
County Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
315 'r`r /aoa�o9, l21z �' w
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6.Ware)the weli(s)0re-rmanent or Temporary SignampofCcrtified W61M.6tractor Date
By signing this form.I hereb cert&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or E)No with I5A NCAC 02C.01W Dr ISA NCAC102C.0100 Well ConstructionStandards and that a
If this is a repair,fill out known well construction Wormation and explain the nature ofthe copy clf h record;;;been p vviLto the well owner.
repair under#11 remarks section or on the back ofthisform. 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 page to provide additional well site details or well
construction,only 1 GW 1 is needed Indicate TOTAL NUMBER of wells construction details You ay also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUGlfIONS
9.Total well depth below land surface: d o (fW 24a.For All Wells: Submit this form within 30 days of completion of well
For tmrhiple wells list all depths tfdiererti(example-3@200'and 1@l00� construction to the following'
00
10.Static water level below top of casing: 1 d) (ft) Division of Wafer Resources,Information Processing Unit,
lfwater level Is above casing use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (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: re.)f A r�/ construction to the following:
(Le.auger,rotary,cable,direct push,eta)
Division of Water Resources,Un derground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
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13a.Yield(gpm) � F6 Method of test: 24c.For Water Suomly,tg Infection Wells:;In addition to sending the form to
the address(es) above, a so submiti one copy of this form within 30 days of
13b.Disinfection type: t: Amount: 13 4 Z completion of-well constiruction to the county health department of the county
where constructed
Form OW-1 North Carolina Department of Environmental Quality-Division of%te!Resources Revised 2-22-2016
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