GW1-2021-06039_Well Construction - GW1_20210901

*V l. me �c,l r3sitt rrrat r ,
WELL ONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: °� o
-77.>
WellCotraetorName �i FROM TO DESCRIPTION
N p1111 ft. ft.
J
$ A r r L'.u ft ft
:,s ' CP
NC Well Contractor t0;1.'.�`�` ,r+ C' '
FROM TO DIAMETERC THICKNESS MATERIAL
�- � 5:flil` 12=C�lSli+t�for:• iilF�ssed woli Y3A.�IAIER tt` _' ifeabt _
6 l a fl !pWell t
e, ' ft. ft. iin.
Company Name
)10 - as 0\1 FROM M ei al.ctusKNE .ATE
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
14
List all applicable well construction permits(i.e. UIC,Count),.State,Variance,etc.) � ft. V f. in. V C,
3.Well Use(check well use): ft. v ft. in•
Water Supply Well:
FROM I TO I DIAMETER SLOT SIZE THICKNESS MATERIAL /
Agricultural � unicipa]/Public ft. ft, in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft n, in.
Industrial/Commercial ®IResidential Water Supply(shared) III G11Qt) s,
irrigation FROM I TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
ft. ft.
Monitoring DRecovery ft. ft. i
Infection Well: ft. ft
Aquifer Recharge ®Groundwater Remediation ;19:SAIVAlt; 1'ACkC d" liei<tia
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft, ft
Geothermal(Closed Loop) OTracer a DR1iY1N :'t): ftaehrlddifloit ;s sets f# Ipeess - '
FROM TO color,hardness,solitrock ,In st etc
Geothermal(Heatin Coolin Return)) ,Other(explain under#21 Remarks f ft � ft DESCRIPTION rid c.
n lie.
4.Date Well(s)Completed: of Well ID# ft. ft.
5a.WV Location:
�,��
��
1 firm
ft. ft
Facility!Owner a Facility ID#(if applicable)
/t( + �r•
ft. fL
Physical Address,City,and ip i ft. ft
`:1 .� I��� 2i.lRElilAltRfi
County Parcel Identification No.(PIN) ' line(- c T. $b
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: a
(ifwellfield,one lat/long is sufficient) 22.Ce ' c 'on:
i y
N W
i a..-
6.Is(are)the well(s) (Permanent or OTemporary 'qWatug OYCertified Well Con ctor to
By signing this form,I hereby certify that t e t+e11(s)was(were)constructed in accordance
7.Is this a repair to an existing well: dyes or [3No with 15A NC,4C 02C.0100 or 15A NCAC 02 .0100 Well Construction Standards and that a
If this is a repair,fell out known well construction h1formation and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on lire 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
construe on,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 6 <+ SUBMITTAL INSTRUCTIONS
9.Total:well depth below land surface: (fti) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdderent(example-3@200'and 2@ 1001 construction to the following:
10.Static water level below top of casing: a (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 24b.For Injection Wells: 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: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) L'3 Method of test: 24c.For Water Supply&Inlection'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:� a completion of well construction to the 'county health department of the county
where constructed, i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016