GW1-2021-03658_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD(GW-1). For Internal Use Only:
1.Well Co:ro
I fo tion:
G 14 WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. /D
_70 y ft: (� fz
NC Well Contractor Cet ' Number I&.OUTER:CASING'for multi :wilt OR LINER of
FROM TO DIAMETER I THICKNESS I MATERIAL
ft. v fL in. vc
Company Name
/ +1 � � ib:;1NNER GA$1NG OIt>TIJSING: ,` dosed-1eo
2.Well Construction Permit#: J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(I.e.UIC.County,Stare,variance,etc.) ft ft• is
3.Well Use(check well use): ft. ra
RE
Water Supply Well: FROM E TO I DIAMETER I SLOTSIZE I THICKNESS I MATERIAL
Agricultural QMun al/Public 0 ft ft- in.
Geothermal(Heating/Cooling Supply) idential Water Supply(single) fL in
Industrial/Commercial Residential Water Supply(shared)
;:18:.GROi1T r
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft Po cdw7cr
Monitoring DRecovery R fL
Injection Wen: ft. fL
Aquifer Recharge Groundwater Remediation
_ 19.:SANDIGRA3'£L`PACK ble
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test C)Stormwater Drainage fL fL
Experimental Technology Subsidence Control ]ti fc
Geothermal(Closed Loop) Tracer 3l1.DRiI,LING TAC..attach addi6ond ahi�f _.
Geothermal(HeatinConlin R ) Other(explain under#21 Remarks
FROM TO DESCRIPTION color,hardness,soil/rocksae,ere.
flu r �
J •
fL
4.Date Well(s)Completed: f 7 well ID#
Sa.Well ation: ft ft.
/t k JteG/ /K_-1 it y h &
Facility/Owner Name Faci'ty ID#(if applicable) fL fL
act 8 & R
Physical Address,City,and Zip ft. ft
Q,&a .2L:REMARKS I r
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Wong is sufficient) 22.Certification:
W
6.Is(are)the wells) Permanent orTemporrry Signature of Certified Well Con or Date
i
By signing this form.I her certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or o with 15A NCAC 02C.010 or 15A NCAC 02C.0200 Well Construction Standards and Thar 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 921 remarks section or on the back of thisform. 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: Jr, ly (D-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdrfjerent(example-3Q20 'andd22@100) construction to the following:
10.Static water level below top of casing: s J (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+ 1617 Man Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Iniection Wens: 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: r G Ila construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-163§
13a.Yield(gpm) 4 D Method of test 24c. For Wate n r SuDly&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 D completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Deparenent of Environmental Quality-Division of Water Resources Revised 2-22-2016