GW1-2021-06590_Well Construction - GW1_20211029

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information: �,q^J
14.WATER ZONES
Well Contractor Name :�J ,Z11 FROM TO DESCRIPTION
L?jar''��• '1
NC Well Contractor Certification Number
r 15.OUTER CASING for multi-egad wells .OR LINER f applicable)
G_1t 1 f 0p w 1J FROM TO DIAMETER THICKNESS MATERIAL
Company Name- ft. 2-ft. in. $g
�' wS 16.INNER CAGING OR TUBING eothertnil cloaed4
2.Well Construction Permit#: ` FROM To DIAMETER THICKNESS IMATERIAL
List all applicable well construction permits#.e.UIC,County,State,Variah e,etc.) it. ft in.
3.Well Use(check well use): n' R' hr'
Water Supply Well: 17.SCREEN.
FROM TO I DIAMETER SLOT SIZE TMCKNESS MATERIAL
Agricultural unicipal/Public
thermal(Reating/Cooling Supply) Residential R. ft. in Water Supply(single) k
.'
%dustrial/Commercial [�Residential Water Supply(shared)
18..GROUT
hri lion FROM TO MATERIAL EMPLACEMENT OD&AMOUNT
Non-Water Supply Well: (,- Ir 4Vtr
Monitoring ORecovery ft. ft. a
Injection Well: ft. fn.
Aquifer Recharge [3Groundwater Remediation 19:BAND/GRAVEL.PACK if a ble
Aquifer Storage and Recovery13Salinity Barrier I TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage R •
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 10.DRILLING LOG attach additional sheets If necessary)
Geothermal eatin Coolin Retum Other lain under#21 Remarks FROM TO DESCRIPTION color bardn solurock IyM grain eta
p ft. n.
4.Date Well(s)Completed: 'e1 Well ID# tt, ��i
Sa.Well Locatlop b R' �hU
& 6 S►c,w 1 G.L ft. ft.
Facility/Oft N Facility ID#(if applicable) It. ft.
1ths rd oa 6vrI�G h. ft.
l Sd k1.
Physical Address,City,and Zip ft• ft.
(a y% 1 h 3 v Q 7 0 21.REMAM
unCo ty - Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the wells)[dPermanent or 13Temporary Signafurl of Certified well C(,n_tractor Date
By signing this form,I hereby cert6 that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or 9No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction iqformation and explain the nature of the copy of this record has been provided to the welt owner.
repair under#21 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.
died' SUBMITTAL INSTRUCTIONS!
9.Total well depth below land surface: y (R-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d�erent(example-3@20�'0''and 2Q100� construction to the following:
10.Static water level below top of casing: 0 C/ (ft.) Division of Water Resources,Information Processing Unit,
Ywater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to standing 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: 6+4 r construction to the following:
(Le.auger,rotary,cable,direct push,atc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY- 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 0 Method of test: (aW 24c.For Water Sunniv&Injection Wells: In addition to sending the form to
the address(es) above, also subniit�one copy of this form within 30 days of
13b.Disinfection type: Amount: 2 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