GW1-2021-06577_Well Construction - GW1_20211029

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Infor/m�ation: f
.JriS'�(. 14.:,WATER ZONU
Well Contractor Name FROM TO DLWREMON
4.54�/- 66- ft. 67 ft-
NC Well Contractor Certification Number Ito R. 117. ft- qrev 44 i•ft
^0� W� _1&?OUTERCASMC- fat*Q r`aecdweite�ORUMIt Ra itea.lc'
� 1 D ri l li o FROM /TO DIAMETER THICKNESS MATERIAL
Compaq N,me t _ f` +1 � G?• tt• G tm S �—Z 1 C
I40/ _a16 DWME CASING ORTUBING(eothermai closed-lno
2.Well Construction Permit#: (' FROM _ To- - DrAMETER TEUCKNEss I MATERIAL
List all applicable well construction permits 6-a UIG County;State Variance•eta) & D• in.
3.Weil Use(check•well use): ft. ft. tn.
Water Supply Well: .'17 SCRREN r:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural DMunicipal/Pubiic N, fL in.
:)Geothermal(Reating/Cooling Supply) BResidentiai Dilater Supply(single)
IL ft. in:
: Industrial/Commercial DResidential Water Supply(shared) ill:GROf1T
ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a & 50_ _ - Qe/1 h' f billp cot�Monitoring Recovery tt. ft.
Injection Well:
Aquifer Recharge E)Groundwater Remediation ft. ft
Aquifer Storage and Recovery EISalinity Barrier Fo AND/GR�VEL.PAC I MATMIALOratitilleali� EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage n• n•
Experimental Technology [3Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.-DR1I.tsINGLOG attach a"Honai4beetsifnecessa
Geothermal(Heating/Cooling Return Odlet lain under#21 Remarks) FROM TO DPSCRIPT[ON color,hardness,soittrock in size,etc)
0 51
- OV�s_ I�usdenl r
4.Date Well(s)Completed: ZO.i! Well ID# SZ tt. 300
Sa.Well Location: ft. D
S cal f'
Facility/Owner Name Facility ID#(ifapplicable) R R• .R^ � �}
GOT C /1 &on Rd, Wortr ep>sv►'I6f Zk693 � ft. `��•;�
Physical Address,City,"and Zip ft. ft.
As
he (L7.14 70350z 21:
i ��1rQ J—)\,tits
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: \`
(if well field,one lat/loug is sufficient) 22.Certification:
141 W _ 911 2
6.Is(are)the well(s) rmanent or Temporary acme of Well Contractor Date 021
By signing this form,I hereby certify that the well(T)was(were)constructed in accordance
7.Is this a repair to an existing well: DY. or �No will[15A NCAC 02C.0100 or 15A NCAC 02C.0200 WWI 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 ofthis 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-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: Soo, (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if djjerent(example-3Q200'and 2(a)100) construction to the following.
%
10.Static water level below top of casing: 6 0 010 Division of Water Resources,Information Processing Unit,
If tester level is above casing,use"+^, 1617 Mail Service Center,Raleigh,NC 27699-1617
1
11.Borehole diameter: b �� ((cin_.)F 24b.For_Iniection Wells: In addition to sending the form to the address in 24a
.12.Well construction method:
A/t 1 1V'!Q�'y above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,dined 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) 10 Method of test: / 'l T 24c.For Water.Supply&Inlection Wells: In addition to sending the form to
i 07. 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