GW1-2021-06686_Well Construction - GW1_20211007

For Intemal Use Only:
WELL CONSTRUCTION RECORD G �- �°4 ,w,�
1.Well Contractor Information:
�e l h �A c ob (1C 1 O ZOZ� 4:wMRwrTEs
TO DESCR>p7TON
Won Contactor Name r— / q� CGr,L'�r�li�� ft. /+t O & /�f
NC Well Contractor Certification Number 15.`OUTER CASING'fw,mattkeluod':®db O$FRO I TO IK. d
D MATIItW.
ft. iE6
Company NA
S
�'`e G -
Z3S- 2�Z 6 I
1 NNER CAIH :oR�1IBING
O J { 1ffiC�iESS a MATFIWL
2.Well Construction Permit#: FROM TO ft. DIAMETIIt in.
List all applicable well c0n0_non permits(i e.UIC,County.State,Variance,etc)
1O•
3.Well Use(check well use): ft iz
water Su Well: FR'sCR&IIV
PPIY FROM TO DIAMETFdt SLOT STLE _ •TH[Cl3FIESS, MATIIWI.<,,
g'tcull Ural 13MumcipaMblic 0 fit. ft
Geothermal(HeatinWCooling Supply) �idential Water Supply(single) ft. & in.
Industrial/Commercial 13Residential Water Supply(shared) to GRt3i1T _-Irrigation FROM TO MATEBIAL E11rPIA METHOD&AMOUNT"
Non-Water Supply Well: Q n• a D ft ��+ Q to f elf
Monitoring p Recovery ft ft
Injection Well:
iL R
Aquifer Recharge Groundwater Remediation
if
Aquifer Storage and Recovery Salinity Barrier FRO TO
MATERML EAUIACEMMM MEMOD
Aquifer Test 13Stormwater Drainage ft. R'
Experimental Technology OSubsidence Control it. ft.
Geothermal(Closed Loop) 13Tracer 2o.DRIId ING LOI .attaeJi addrfioniiieheetb'if.
Geothermal Heatm Cooling Return Other(explain under#21 Remarks) FROM TO DESCREMON color,hardam ' rack tee.em
O ft' '� O Se'l
4.Date Well(s)Completed: y a Well ID# C Q
lmn. nn G fi' 4 C) ff' .SCII't
C( renZ'2 Yy\CVr-V hut• L O R ay it &rao.
tf—
Facility/Owner Name Fac''ty lD#(if applicable) & ft.
fL It.
Physical Address,City,and Zip & ft.
11J
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W ' 2 //
6.Is(are)the well(s)ePermanent or Temporary Signature of Certified we Contractor Date > �l
By signing this form,1 hereby cert#y that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or 6No with 15A NCAC 01C.0100 or 15A NCAC 02C.0100 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: d -1 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di,�erent(example-3 a) 00'and 2@100') construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
If water level is above caring,use-+••r,, 1617 Mail Service Center,Raleigh,NC 276"-1617
11.Borehole diameter: v (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Wen construction method: G�Gtr^� 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) y Method of test 0 w 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136 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