GW1-2021-05529_Well Construction - GW1_20211013

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Infor tion:
77 V� Tbbl"', eAl e--
Well Contractor Name FROM TO DESCRIPTION
® '� O \ ft. O ft. �0 j M
�— `� 1 a7 �1C\�\ 1� ft. fL 4
NC Well Contractor Certification Number 0 y ro5 15. T3TE1t CA51AICt trrrid . '' ' f)R $ t["a"' uEi[
62 ���(� FROM TO DIAMETER THICKNESS MATERIAL
Q 8 �: CQG,. Uu ft. fr. In-
n YI1n1
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Company Name
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2.Well Construction Permit#: a I' 0041 FROM TO DIAMETER THICKNESS MATERrALa
List all applicable well construction permits(i.e.VIC,County,State,Yariunee,etc.) ft. ft. in.
3.Well Use(check well use):
Y.
Water Supply Well: FROM I TO I DIAMETER I' IZ SLOT SE THICKNESS MATERIAL
Agricultural Municipal/Public ft, tt, in.
Geothermal(Heating/Cooling Supply) BRosidential Water Supply(single) ft. ft. in.
Industrial/Commercial 13Residential Water Supply(shared) ,1S:GRf1111`
Irrigation FROM TO MATERIAL Y EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. d ft. d u r, r 4 V
M .onitoring Recovery ft. ft.
Injection Well:
fr. ft.
Aquifer Recharge DGroundwater Remediation
19 S /G 1r pAt 'it eaYtte ,.rz
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) DTracer D G" t3D atfircli addit! niil<shttaiiiEcessa r
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks) PROM TO DESCRIPTION Coto.,hardnemsoiureck type,graln size,"eta
ft. a ft.
ID#q �� ll Well 3 ft. tt. I
4.Date Wells Completed: P
5a.Well Locado o ft goo. tt. r ^ G V,G G
i R. ft. ft.
Facility/ wnerNi'Ecic;J
1�FacilityIDW(ifaappli{c�a1ble) Cdt_ ft. ft.
n, r V'�pe� 11I IVL.��JAP ft. ft.
Physical Address,City,and Zip —T— ft. ft.
f(A VIAf.
County J arcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(long is sufficient) 22.Ce •fieation:
N W oil n Z )
6.Is(are)the well(s) Permanent or Temporary Sigma of Certified We 1 Contractor Date /
By signing this form,I hereby certify that the iwll(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or R(No with 15A NCAC 01C.0100 or 15A NCAC 01C.0100 well Construction Standards and that a
Ifthis 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 421 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: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 400 (fr-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di,(ferent(example-3Q200'and 2@1001 Construction to the following:
10.Static water level below top of casing: a 0 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: l (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: �'b-1 f above, also submit one copy of this forme within 30 days of completion of well
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: t 1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) as Method of test: " D� 24c.For Water SuDDIv&Infection Wells: In addition to sending the form to
f the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 2 J 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