GW1-2021-06507_Well Construction - GW1_20211027

yyr+LL1.VENO11CUL11V1V 1tLLC01W ((iW-11 For Internal Use Only:
1.Well�Q Contractor Information:�'�y�1 V V i I I� 1 if�V1 1 Y 14.WATER ZONES
Well Contractor Namel FROM TO DESCRIPTION
ON aft. ft
ft ft.
NC Well Contractor Certification Number
IS.OUTER CASING for multi-cased wells OR LINER rf a licable
FROM TO DLt,.A£ETER TffiCKNESS M(A�TER1AL
Company Name
�( { I ft _q� ft in. L �� P
16.INNER CASING OR TUBING, eoLhermal closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.,U1C.County,State, Variance,etc.) ft ft in.
3.Well Use(check well use): . ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_ Agricultural [IMunicipal/Public as ft. `� ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) vS ��� 0 PYG
ft
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
hri ation FROM TO MATERLAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft.
Monitoring
Inj p�Recove D
LJ ry ft ft DD_xr,
ection Well:
Recharge ft. £t.
:)Aquifer g Groundwater Remediation
Aquifer Storage and Recovery 19.SAND/GRAVEL PACK(if a licablc
quif S g ry �ISalinityBarrier CDRILLINGOLO',
MATERIAL EMPLACEMENT METHOD
Aquifer Test O Stormwater Drainage fta
Experimental Technology oSubsidence Control ft
Geothermal(Closed Loop) �ITracer G(attach additional sheets if necess )
_ Geothermal(Heating/Cooling Return) MI Other(explain under#21 Remarks) DESCRIPTION(color,hsrdn sotl/rock is size eta
ft4.Date Wells)Completed: - Well ID# fz
s
Sa Well Location: fz ft
v' ft. ft r
Facility/Owner Name n Facility ID#((iiiffapplicabrle)) ft ft
Physical Address,Cl ,end Zip ft ft
00'vao 1509 _A_9((AL1ry)() 11.REMARKS
County Parcel Identification No.(PIN) 2 1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r jn Unit
(ifwell field,one W/long is sufficient) �7 22.Certification: Roar-3'wR SgCClpn
35 , 339 q?g N �— 1 l�c(U' ��� J5� W 1 �
6.Is(are)the well(s)PPermanent or QlTemporary Yignature of Ceafied Well Con or Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: MYes or No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information nd explain the narure ofthe copy ofthis record has been provided to the well owner.
repair under#21 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 I GW-I 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: C A) 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 2@1001
construction to the following:
10.Static water level below top of casing: 13 (fL) Division of Water Resources,Information Processing Unit,
ifutter level is above casing,use ,+,, 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 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
I2.Well construction method:��(i.e.auger,rotary,cable,direct push,etc.) 0
construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a Yield(gpm) Method of test: MYNI � 24c. For Water Suonly&Iniecti"on Wells: In addition to sending the form to
1 I 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 Qualiry-Division of Water Resources Revised 2-22-2016
1