GW1-2021-06788_Well Construction - GW1_20210809

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WELL CONSTRUCTION. RD GW-1 �
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For Internal Use Only:
1.Well Contractor Information:
44.-:WATERZONFB
Well Contractor Name
^^ FROM TO .DESCRIPTION
eZ00ft' 30o ft. i
i
ft. ft.
NC Well Contactor Certification Number i
j 15:`f1�Tfii�R:>c;g1NG, �t�u>tt-ealeIIitis ORr �.
AW +'na-yy r ' FROM TO DIAMETER THICKNESS MATERIAL
Company Name fL fL Iin.
�f 16 31IER-Gi�51NE�(iR.
2.Well Construction Permit#: —Z FROM To DIAMETER ri TffiCKNES3 L
N MA TE RIA List all applicable well construction permits(I !U/ ,C'ounN.State.variance,etc) +' fL it ft,
O d fL
3.Well Use(check well use): ft. If. In
Water Supply Well: :17:SCREii
'j FROM
Agricultural u TO nicipal/Public DIAMETER SLOT SIZE THICKNESS MA TER IAI.
ft. ft. in.
Geothermal(Heating/Cooling Supply) dentin
Water Supply(single)
Industrial/Commercial ft. ft in
esidential Water Supply(shoed)
Irrigation
FROM Non-Water Supply Well: ft.
RMATERIALx+ HEMPLACEMEM1?M ETHOD&AMOUNT
I i I O 23� tL
Monitoring I
ecovery ft. ft.
Injection Well: i j 6r
Aquifer Recharge I roundwater Remediation ft ft.
( 14:$A1VDtG3i n -
Aquifer Storage and Recovery ® linetyBarri Barrier FROM ro
Aquifer Test
MATERIAL EMPLACEMENT METHODj I r3i winwater Drainage ft. ft,
Experimental Technology ;;� bsidence Control ft. tL
Geothermal(Closed Loop) cer 20"1?RIL11i11GflG' .,..
Geothermal(Hearin Conlin Rehm EX FROM To M1(color,Aardn
her(explain under#21 Remarks) ft, DFSCRIPTIO ess soi0roek e, m Shp,etc.)
ft.
4.Date Well(s)Completed: '3 L
�We11ID# ft. ft. I(u 4, -
59.Well Location: ft. ft,
scd�e w► c l�r. n4 Ytvv t S Facility/Owner Name Facility ID#(if applicable) ft ft.
ZI -
o ft. ft.
Physical Address,City,and Zip 1 ft ft
County I Parcel Identification No.(PrN)
5b.Latitude and longitude in degrees/lutm,seconds or decimal degrees: ,, tJ�V
(if well field,one lat/long is sufficient)
22.Certific
e atio �t11� Q
N �iw►""r
6.Is(are)the wells) rmanent or! mporary ate oa Signature Of Certified Well Contractor Date
� By signing this form,1 lrerebv ce7lif that the wells)was(were)c•onctructed in accordance
7.1s this a repair"ad an existing well: �Ye or 1. ° With 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
Ijthis is a repair,fill aeit known well constructed info Lion and explain the nature ofthe cOPY ofthis record has been provided to the Kell owner.
repair under#21 remarks section or on the baci f'the rm.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Mtho al 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. Indi6ate TAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: Ii I
i ; SUBMITTAL INSTRUCTIONS
9•Total well depth below land surface: 111 13 , (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(exattf�le- �00'and T@100�
construction to the following:
10.Static water level below top of casmg:,1 G
if water level is above casing,use"+ A) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:
R 6' 24b.For Iniection 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
(i.e.auger,rotary,cable,,direct push etc.) I ! tY construction to the following:
is
FOR WATER SUPPLY WELLS ONLY:,;' Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) letho f test: rY' 24c.For Water Sunnly&Injection Wells: In addition to sending the form to
I':13b.Disinfection type: the address(es) above, also submit on`e copy of this form within 30 days of
I ount:- 2. t✓ completion of well construction to the4 county health department of the county
where constructed.
Form GW-1 N Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016
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