GW1-2021-06627_Well Construction - GW1_20211007

\ GW-1 For Intemal Use Only:
WELL CONSTRUCTION RECORD
1.Well Contractor Information:
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PROM TO DESCRIP rRON
Well Contractor Name ^0�1 ft. 1 ft.
NC Well Contractor Certification Number
�t`Onp1r�U�'O� OITTER:CTOSING::forrtt wcllri`D� s� MATERIA
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/I 16 1NNEtt t A51N =0 Company Name izIBING
I I FROM TO DIAMETFAt ^THR9INFSS MATERIAL
2.Well Constriction Permit#: I th th ;o,
List all applicable well construction permits(Le.UIC.County,State,Variance,etc.)
3.Well Use(check well use):
-11 SCREEN ,
water supply well'. FROM I TO I DIAMEfER SLOT SIZE I IMCKNEM I MATERIAL
gricultural 13M cipal/Public 0 fL ft. in.
Geothermal(Heatmg/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 1s GROAT _ _ =•
Irfigation FROM TO MATERIAL II1IPLACF2FffiVT D&AMOUNT
Non-Water Supply Well: G ft Q ft �C U G(A(-e
Monitoring Recovery & fL
Injection well: ft. fL
Aquifer Recharge Groundwater Remediation _
Aquifer Storage and Recovery Salinity Barrier FROM TO PAS MATERIAL EM1'LACMa�N=011, `
Aquifer Test 13Stormwater Drainage ft R
Experimental Technology Subsidence Control fa ft.
Geothermal(Closed Loop) Tracer �20:DRILdiINGLOG:attachaddr6onal,sheeiiif:
Geothermal eatm Coolin Return Other(explain under#21 Remarks) FROM TO DESCRWHON color,bwdm s,soirhoek OVO, roe,dc.
C5 fL3 ft.
4.Date Well(s)Completed: Jv Well ID# tt 9,0 & C'
5a.Well Location: 6 fL fL �Q n
El" kas r-p & ft.
Facility/Owner Name Facility ID#,(if applicable) R' N'
GJ'5-- "t-j /�-* 4 11\-h r �,n/`vlA/ ft. ft.
Physical A`dd&=,City,and Zip ft. ft.
County ParcelIdentificationNo.(PIN) � ee or -n �� S hd�
5b.Latitude and longitude in degrees/minates/seconds or decimal degrees:
(ifwell field,one tattlong is sufficient)
22.Certification: /N W ,
6.Is(are)the wells) Permanent or OTemporary Si ofCertified Well Con for 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 ENo with 15A NCAC 02C.0100 or ISA 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 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: t1< (fL) 24s. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths tfdii ferent(example-3@200'aan}d 2@100') construction to the following:
10.Static water level below top of casing: �v (ft) Division of Water Resources,Information Processing Unit,
lfwater level is above caring,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: V (in-.)/ 241.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: y�On r 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 27699-1636
13s.Yield(gpm) Method of test- LA) 24c.For Water Supply&Inieetion Wells: In addition to sending the form to
the address(es) above, also submit one copy of this fora within 30 days of
13b.Disinfection type: 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