GW1-2021-06591_Well Construction - GW1_20211029

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WELL CONSTRUCTION RECORD(GW-1) y,� For Internal Use Only:
1.Well ContractorInformation: W
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WellContractorName ,1 �� ti ,1FROM I TO DESCRiPTTON
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NC Well Contractor Certification Number ��?;`t'• �\;ur: _5
PIE-" iilieltl`-e4ai� �31€ R. lt�a>i!e
FROM ft TO DIAMETER In TIUCKNESS MATERIAL
Company NNa\\me t,77777
ln, ;16li+tAlklt` RiTll$ 6' bttiiaaat=tiad+i6" V'
2.Well Construction Permit#: v C/. FROM To DIAMETER I THICKNESS I MATERIAL
List all applicable well consh'uction permits ti.e.VIC,County,State,YariAi ce,etc.) tt. ft. 1n
3.Well Use(check well use): ft, tt. in.
wnter-'Supply Well:
IFROM I TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
Agricultural ® icipal/Public tt. it. in.
Geothermal(Heating/Coohng Supply) esidential Water Supply(single) it , ft. inJ
Industrial/Commercial 13Residential Water Supply(shared) z
Irrigation FROM TO MATERIAL EMPLAC METHOD&AMOUNT
Non-Water Supply Well: 0 it. 0 ft. ,6 r
Monitoring - Recovery ft. ft.
Infection Well: ft ft.
Aquifer Recharge 00roundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology [3Subsidence Control
Geothermal(Closed hoop) 13Tracer N2tIt 3G attic ell adeBfi' I6r e3fFpe" =`, ._
Geothermal(Heatin Cooling Return) 0Other(explain under#21 Remarks FROM TO DESCRIMON` for hardness soiltrock in Am etc.
1
4.Date Well ps)Completed: �1 well ID# d� ft. v ft. A
5a.Well Location:
(Location: 'Q l ff $G Q e. C
d6G1
V
Facility/Owner Name Facility ID#(if applicable) ft. ft.
_A% 0MV61 T W- ft. ft.
Physical ddress,City,and zip q ft ft.
b h� 4f'.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwefl field,one lat/long is sufficient) 22.Ce ' eatfo ii
6.Is(are)the well(s)WPermanent or OTemporary Si tore of Certified Wet om c., Date
i4y igning this form,I h eby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or No with 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#11 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
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also(attach additional pages if necessary.
wed'--I-- i SUBMITTAL INSTRUCTIONS j
9.Total well depth below land surface: 1�O (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diperent(example-3@200'and 1@1001 construction to the following:
10.Static water level below top of casing: 2 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+'1) 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 1� (in.) 24b.For Iniecdon 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:a 1'r construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
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 SuDDiv&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. j
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016