GW1-2021-04282_Well Construction - GW1_20210901

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: "
s ..
FROM TO DESCRIPTION
Well Contractor Name S 1. e1y ft Oo ft. f O w
a96
NC Well Contractor Certification Number �lil"14' FROM TO DIAMETER ` ~
©DLV'`• FS.AUIER(3AsfNG.forma TAME ER 1HICKKM h
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Company Name G 16:WNER CA91NGV1VJ oBWG#
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(r.e.UIC,County,State.Variance,etc.) ft' ft' 1O
3.Well Use(check well use): ft.
Water Supply Well: FROM
I TO p. it :SLOT SIu i►�f TERUL'tj"
❑Agricultural ❑Municipal/Public ft I ft. I in
❑Geothermal(Heating/Cooling Supply) L°f esidential Water Supply(single) fL & is
Oladustrial/Commercial ❑Residential Water Supply(shared) r
�1R=GROTTY f .� w�•��._�*....
DIffigation ❑Wells>100,000 GPD FROM TO MATERIAL. EMPI.A METHOD&AMOUNT
Non-Water Supply Well: ft. ft. aAre
❑Monitoring ❑Recovery ft. ft
Injection Well: ft.
❑Aquifer Recharge ❑Groundwater Remediation
?f9.�Si4ND/GItiAVEL�PA. c=`
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL gMPL ACENIIflVTMETHOD
❑Aquifer Test ❑Stormwater Drainage % ft
❑Experimental Technology ❑Subsidence Control ft. fL
❑Geothermal(Closed Loop) OTracer 211.DItIt I61NG'f;OO.+iiaildtt[ooiil!ti�dfexitneea` c �.,,:. ..
❑Geothermal(Heating/Cooling;Return ❑Other(explain under#21 Remarks FROM TO DESCRIPTION(color,
r hudn wWmck eta
O ft ff. 0 SQ
4.Date Well(s)Completed:- 0 Well ID# ft' G ft. (�
5a.Well Location: Q ft. �G ft ,SQ h
f rif C4 irn-sSey— fL L ft.
Facility/Owner are F ty ID#(if applicable) ft. ft.
/Y�f S,Id m.t �<n e I( ft. ft.
Physical Address,City,and Zip ft. ft.
Trin
County Parcel Identification No.(PIN) e
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Wong is sufficient) 22.Certification: � �f
N Wz4z C�c O,/r /'tea/^a L
6.Is(are)the well(s): QPermanent or ❑Temporary SignaVA of Certified well onnactor Date
By signing this form,I hereby certify that the well(s)was(mw)constructed in accordance with
7.Is this a repair to an existing well: Oyes or QNo 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the 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:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page ito provide additional well construction info
construction,only 1 GW-i is needed. Indicate TOTAL NUMBER of wells (add.See Over'in Remarks Box).You may also attach additional pages if necessary.
filled' /J 24.SUBMITTAL INSTRUCTION
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9.Total well depth below land surface: / / (ft) I
For multiple wells list all depths ijdifferent(esmnple-3Q200'and 2@1001 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: )-0 (ft.) 24a. For All Wells: Original forin to Division of Water Resources (DWR),
Ijwarer level is above casing,use"+r"l2 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
/� 4 Program,1636 MSC,Raleigh,NC 27699-1636
1L Well construction method: 4\� a 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of a county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing Iver 100,000 GPD:Copy to DWR,CCPCUA
1- / Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: OV'�
13b.Disinfection type: Amount: _
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 64-2018