GW1-2021-06593_Well Construction - GW1_20211029

I`El,{rr}{sari *
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
;10601N =
Well Contractor Name � FROM TO DESCRIPTION
� f U� `1 i f. 71� ft. �l th
NC Well Contractor Certification Number r.•. Z i n If yi
a ilb it
I �� 'S' �Oti4,"� ✓v., 15,�T3TF,4t: "' or-, ` '.11i1VF'i12: bib' s z..,':, .. -•.
p t L� FROM TO DIAMETER THICKNESS MATERIAL
L R. to fn.
Company Name
t�r pp t6;• Ler "a'll3 C's ,. ,th'gtai�lbsed-iu": ; '� .; �;. -
2.Well Construction Permit#: (s �l — ©10 5(y 10 I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Count),,State,Varidrtte,etc.) ft. ft. in.
3.Well Use(check well use): tt. ft. in.
Water Supply Well: 1Ta`St M
FROM I TO I DIAMETER`, SLOT SIZE THICKNESS MATERIAL
Agricultural gmunicipaMblic ft. ft. in
Geothermal(Heating/Cooling Supply) IRResidential Water Supply(single) ft. ft. in
Industrial/Commercial Residential Water Supply(shared)
Irrigation FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT~~
Non-Water Supply Well: ft. 200 ft- 1 ,
;fy
,Monitoring Recovery ft. ft. I Q ,
Injection Well: ft. ft. CAA
Aquifer Recharge [3Groundwater Remediation'
�1§.=5A�II31(xltzl'vL !tt a"Ai�i. "ma`s ��::�? �'�s`"
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft
Experimental Technology 13Subsidence Control
Geothermal(Closed Loop) 13Tracer 20.; Rt LlftO`#tyG iitiiit8dltfn' .t #r if hEcess" _?
Geothermal eating/Conlin Return Other( lain under#21 Remarks) cock
FROM TO DESCRIPTION color,hardn sail/rack in size,etc
4.Date Weil(s)Completed: >l �1 "�� Well ID#
5a.Well Location:
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft.
ft
Physical Address,City,and Zip /
County Parcel Identification No.(PIN) r t0*
44
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �� Q
(if well field,one lat/long is sufficient) 22.Certification: 'l
N W ' � lb -
6.Is(are)the well(s) permanent or 13Temporary SignatuWof Certified Well Co tractor I Date
By signing this form,I hereby certfy that the vtvll(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or 13No with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 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 421 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
wed' I SUBMITTAL qqoINSTRUCTIONS
9.Total well depth below land surface: (ft 24a. For All Wells: Submit this':form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 1@1001 construction to the following:
10.Static water level below top of casing: / 00 Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+;' 1617 Mail Service Center,Raleigh,NC 27699-1617
e
11.Borehole diameter: _on.) 24b.For Iniection 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 h,it 11 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
13s.Yield(gpm) Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the fort to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 1 completion of well construction to oe 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 y,,