GW1-2021-05532_Well Construction - GW1_20211013

WELL CONSTRUCTION RECORD(GW-1) 1< For Internal Use Only:
1.Well Contractor Information:
✓� 1 R (. .R W DESCRIPTION
ZONES I
Well Contractor Name O U
g1S1� ft. ft. 2- �s P�
�r
3 ®may -1 ����n ��C�IOr
NC Well Contractor Certification Number �fiEJ+� 0�' rsi OUTER'CASnYG`rtirmultl cased',ells;OItLIIiER Ira`ncable "
t1 0 FROM TO DIAMETER THICKNESS MATERIAL
In-
Company Name ,24
16.INNER CASING OR TUBING eothermel ciosed-loo ,
2.Well Constraction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(ie.UIC.County,State,Variance,etc.) ft• ft• Jn•
3.Well Use(check well use): ft ft. 1n.
Water Supply Well: 17::3CREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public 0 ft, ft, in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single)
__:Industrial/Commereial Residential Water Supply(shared)
18.GROUT;;-
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. t i r
Monitoring _Recovery ft. ft.
Injection Well: fL ft.
Aquifer Recharge OGroundwater Remediation
'19.SAND/GRAVEL MACH if a ncable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_ Aquifer Test OStormwater Drainage ft• ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTra= 20.DRILLING LOG attach'additional sheets if
Geothermal Heatin Coolie Retum Other a lain under#21 Remarks FROM TO DESCRIPTION(color,hardness,solitiock 'size,eta
4.Date Well(s)Completed: 10-21 Well ID# `7 ft• Y ft•
5a.Well Location: ` , ft' ft•
W ) ft. l ft.
Facility/Owner Name Facility M9(if applicable) ft. ft.
1 - n/Y10 p <- rd. Ray, r r7 ft ft.
Physical Address,City,and Zip ft. ft.
-21:REMARKS -
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.CertifeatiOn:
(Illiag_�2�
6.Is(are)the well(s) Permanent or-E3Temporary SignililluregrCerfified Wel Contra Date
By signing this form,i hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an eidsting well: Dyes or Eo with 15A NCAC 02C.0100 or ISA NCAC 02C,.0200 Well Construction Standards and that 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#21 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary,
drilled: l p SUa HTTAL FASTRU 71 IONS
9.Total well depth below land surface: 10 6)0 (D•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3©200'and 2@1001 construction to the following:
10.Static water level below top of easing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above acing,use +^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. rJ (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 2L
above, also submit one copy of this form within 30 days of completion of well
� �(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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test: /t t'1: .4*.For Water Suvoly&Ltiection 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: Z 7MA"e r 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 2-22-1