GW1-2021-07133_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD GW-1 ® For Internal Use Only:
1.Well Contractor IKtion:
VVJ (.
r FROM TO DESCRH`T10N
\'ell Contractor Name \. ?CQCelbso �� ,vft- ft-
_ if l7. 1,j0Vvr3t>�RSed�%e� fit fit
NC Well Contractor Certification Number Q 15.OUTER,GASING for,"imolti'ised;rvells 17R t iNER,ilia ' icatite ..
(/'�,� I I FROM I'O DIAMETER 'rHICKNM;SS M.4'I'I;R IAL
I I I�y VIJQ l rl 1 I ��1 fL ft. in.
Company Name or
�]
� _ ��� / 16`INI R;CA$,INCUR.�UBINObthiiialsxos,Cd,IQ'6
FROM TO DIAMETER THICKNESS
2.Well Construction Permit#' lYL4TE1rIA1.
List all applicable well construction permils(i.e.UIC,Counrv,State. Variance.etc.) 1't. Ct. /, In. snk Pvc
3.Well Use(check well use): et. Ct. lJ in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public fit. Ct. io.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
)Industrial/Commercial Residential Water Supply(shared) 18. RpEJT ....> ...:. ....... ..
irri ation FROM TO MATERIAL FMPLACEMENT METHOD&AI110UNT
Non-Water Supply Well: O fit. ft. r
Monitoring ORecovery ft. CL 6>7
Injection Well:
fit fit.
Aquifer Recharge DGroundwater Remediation
19 SAND/GRAVEL PACK .: ......:
Aquifer Storage and Recovery Salinity Barrier FRonI TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [DStonnwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. fit.
Geothermal(Closed Loop) Tracer 20.DRILLTNr IL06 attach'addition5lshi,etsifltecessa": ?..
Geothermal(Heating/Cooling Return) :Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type.gnin size,etc.)
D fL fr. C
4.Date Well(s)Completed: Well 1D# ft.
5a. t 11 Location: ft.
rt. ft.
Y 6t
Facility^/ \ erNName� 1 ] J FacilitylD#(ifapplicable) fit. ft.
IQ /tti ' / /T S E�CY �//I(�Pi�\�j��(�- ft. ft.
Physical Address,City,and Zip I ft. ft.
C�,�l zIt11EMr'.Kx►s�� �i
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Ce tcation:
N 0&,�b .�. 3 NA. Y -2 -2
1 ALL-
6.Is(are)the well(s) Permanent or nTemporary Signature of C I led Well Contractor Date
Br signing this firm, /herchv certili,that the well(s)wav(ivere/constructed in accordance
7.Is this a repair to an existing well: Yes or ONo with 15.4:VCAC 02C.0100 or I5A N(AC QC.0200 Well Construction Standards and ghat a
ifthis is a repair.fill out known well construction information and explain the nature gfthe copy ofrhis record has been provided to the hell owner.
repair sander 921 remarks section or on the back oflhis ftrnu.
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 constnuction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2 .0 (ft:) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi[jereut(example-3(&,200'and 2@100') construction to the following:
i
10.Static water level below top of casing: (ftJ Division of Water Resources,information Processing Unit,
If wafer level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: W (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
JJ above,also submit one copy of this'form within 30 days of completion of well
12.Well construction method:A,// /T� 6l/��� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,jUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) i0 Method of test: ✓ 24c.For Water Sumily& lniecfion Wells: In addition to sending the form to
the address(es) above, also subinit''one copy of this form within 30 days of
13b.Disinfection type: Amount: ) il completion of Well construction to the county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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