GW1-2021-06041_Well Construction - GW1_20210901

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
41A s o� PooWell Contractor Name a t• FROM TO DESCRIPTION
20A� ft 0 ft
I
aa-7 q A sty `r g L ft. Leas ft
NC Weil Contractor Certification Number / t`11111
Y'&.tt)TR+G' fforanuati=cased•:_ s tIRI7NE1r ; itoabl
r
3%' FROM TO DIAMETER THICKNESS MATERIAL
Ca�'ady Paale QI 'x���r�.' `� .olio �^
Company Name (l
2.Well Construction Permit#: �JJ� 1 FROM TO I DIAMETER I THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. tt. in.
Water Supply Well: _17�t REN ; -77
FROM TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural C] unicipalftblic tt. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. tt. in.
Industrial/Commercial Residential Water Supply(shared) 1$ x
Irrigation FROM TO ATFRYAi. EMPLAgLWI5 METHOD&AMOUNT
Non-Water Supply Well: 0 ft. �L p fLhem h 1 f rq Y
Monitoring . Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 13Groundwater Remediation
19:. f MI.-
Aquifer Storage and Recovery 13 Salinity Barrier FROM I TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology 13 Subsidence Control
Geothermal(Closed Loop) Tracer 20 T11tID11NGTG >Eit;i `adeittiig` s7Rertstthe a" f
Geothermal(Heating/Cooling Return) r3 Other(explain under#21 RemarkLj FROM TO DESCRIPTION color,hardness soiltrock rain si7p,etc.
t Q ft. a ft. a
4.Date Well(s)Completed: a` Weil 1D# tld Q it. d ft. Q
5a.Well Location: G ft. ft. e G k
6asA,ir Aull fir (/� u ft. ft.
Facility! erName scilityID# fapplicable) ft. ft.
1161 S r l 1 J ft ft
Physical Address,City,and Zip ft. ft.
W1k kQ, 7553�7 ga _ > r
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C tifieation:
N w
6.Is(are)the wells) Permanent or Temporary Sig&Gre of Certified ell Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or dNo with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 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
construcil
on,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 460 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 1@100D construction to the following:
10.Static water level below top of casing: / 0 0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+"r 1617 Mail Service Center,Raleigh,NC 27699-1617
(P
11.Borehole diameter: (in.) 24b.For Infection 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: �0 ary(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) Method of test: 24c.For Water Suvvly&Iniection 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: ! ��, 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