GW1-2021-06139_Well Construction - GW1_20210809

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WELL CONSTRUCTION RECORD(GW-1). For Internal Use Only:
1.Well Co r nformation:
e Q 14 WATER ZONES .
FROM I TO I DESCRI11,TION
Well Contractor Name R Af,
7 e 112 & Vfr-
NC Well Contract or C Number 15.'OUTER:CASING'for mct6 cased w' OR LINER if a
/• FROM To DIAMETER TMCKNESS MATE L
Q ft 0 fL in.
Company Name Q
�� �� ) !&'.iNNRR C:.UR:TUBIN . �'t1 dined-leo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(I.e.UIC.County.State.Variance,etc.) ft. ft. 1D
3.Well Use(check well use): ft in.
Water Supply hWell• FROMREEN`
TO DIAMETER SLOT SUE THICKNESS MATERIAL
Agricultural QMunt blic 0 ft fL in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fL in.
Industrial/Commercial 13Residential Water Supply(Shared) JM.6ROUr-
Irrigation FROM TO MATERIAL EMPLACEM METHOD&AMOUNT
Non-Water Supply Well: f ' o & e
Monitoring Recovery fL fL
Injection Well:
ft. fL
Aquifer Recharge [3GroundwaterRemediation 19•.SAND/GRAVELPACH , bk
Aquifer Storage and Recovery ®Salinity Barrier FROM To MATERIAL I EMPLACEMENT METHOD
_. Aquifer Test [)Stormwater Drainage %
Experimental Technology OSubsidence Control fc fo
Geothermal(Closed Loop) Tracer `'-2&DREUJKG:LOG..atmrh additioHal ati of
FROM TO DERMET7 N color,hardness,soiUroc4 sim etc
_ Geothermal(Heating/Cooling Conlin ) Other(explain under 921 Remarks
ft 5-,fL I
4.Date Well(s)Completed: Well ID# 9-ft 1^
Sa 11 Location: fL fL
� f ' ft. R .
e4
Facility/Own amc F dity ID#(ifapp cable) ft. ft.
� ft ft
-� to a l
Phyysical City,and Zip fr.40", fL
21.:REMARES p�
County Parcel ldenfification No.(PIN) ld� +Pri
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: V , o� \
(ifwell field,one IwAong is sufficient) 22.Certification:
W
6
6.Is(are)the we11(s) ermanent or Temporary Signature of Certified ell ntractor Date
� By signing this form,I hereby certlfyt That the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or If3"1 with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction SW 1,rds and drat a
If this is a repair•fill out known well construction information and explain the nature of the copy of this record has beenprovided to the well owner.
repair under 921 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: U (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For muhtple wells list all depths ff different(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing: �© (fL) Division of Water Resources,Information Processing Unit,
Ifwater 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:
above,also submit one copy of this form within 30 days of completion of well
�O w",
(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'ICenter,Raleigh,NC 27699-1636
13a.Yield(gpm) J0 Method of test-. r °7 24c.For Water Suvoly At Injection Wells. In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction'to the 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