GW1-2021-06589_Well Construction - GW1_20211029

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.W Con�\tractor info nation, � �q' '� �a
Well Contractor Name i �� Q—ter
FROM TO DESCRIPTION
ft. o m
NC Well Contractor Certification Number Qi1
�� FROM TO DIAMETER THICKNESS MATERIAL
Company Name ?.„
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County;Sta' te,tarries,etc.) ft• ft. in.
3.Well Use(check well use): tt. tt. In.
cum
water-Supply well: 04 FROM TO DIAMETER' SLOT SIZE 1 THICKNESS I MATERIAL
Agricultural ®MunicipaW/ ubuc; ft. tt bw
Geothermal(Heating/Cooling Supply) 13RCsidential Water Supply(single) ft. R, in.
Industrial/Commercial Residential Waters 1 shared T
Supply(shared)
Irrigation FROM TO MA a EMPLACEMENT METHOD&AMOUNT^-
Non-Water Supply Well: ft. fL
Monitoring Recovery ft. ft.
Injection Well:
Aquifer Recharge Groundwater Rernediation R.
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Traceri 4ir" it+ "a atiteYr31E" ` s1i
Geothermal satin Coolin Return) Other(explain under#21 Remarks FROM TO DESCRIPTION eolor,hardness,tolllrack, rain s eta
ft. 5 ft. C (A
4.Date Well(s)Completed: a I Weil ID# R ® 1 e t—k
5a.Well Location: qQ tt. ft' - 7 A le rot.
� u tt it.
Facility/Owner Name Facility M#&f applicable) ft, ft.
Physical A sass,,/Ciity,,and Zip ft ft.
At n4
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,onelat/long is sufficient) 22.Ce ' cation i
6.Is(are)the wefl(s) Permanent or Temporary Si Certified well Contractor Date
by signing this farm,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
t/'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 4021 remarks section or on the back of thisform.
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
dined: j r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: -T 2- -(ft) 24a. For All Wells: Subunit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
I
10.Static water level below top of casing:_ 10 10 (ft.) Division of Water Resources,Information Processing Unit,
Jfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 24b.For Infection Wells; In addition to sending the form to the address in 24a
1e above,also submit one copy of this form within 30 days of completion of well
(Le Well construction method: i f'_� �'` d /
(i.e.anger,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 Win.) ge Method of test: 1�' 24c.For Water Sunoly&Iniecdon 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: I A a completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016