GW1-2021-06238_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1:wm7
1.Well Contractor Information:
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FROM TO DESCRIPTION
Well Cttalct�ojrN V f- /y fL G�ww/spot(
(on4 g Name
1 0 1 11f IL IZZ. fL
NC Well Contractor Certification Number 15:(?IgIERClI$iPlG fvi:mnitt t3R'1 ` � r=
FROM TO I DIAMETER I THICKNESS MATERIAL
(.a nova S y%dm Xd (*,4rtA5Wbll L LC .{, ft. � fL 1 t q to ,� qo PVC
Company Name W
16� It;ci _..>; r ',
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3t 46gl WWM12kg`1 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: fL in.
List all applicable well construction permits(ix.C%IC.County.Slate.Variance.etr.)
IL
fL t6
3.Well Use(check well use):
Water Supply Well: I FROM I TO I DIAMETER SLOT SIZE THICKNFSs MATERIAL
IN.
gricultural E]Municipal Public 0 18 fL 27. fL 1/ in .OIO St(q�f 0 PV
eothermal(Heating/Cooling Supply) vWResidential Water Supply(single) fit It in
ndustrial/Commercial 13Residential Water Supply(shared) -
Irrigation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
n-Water Supply Well: V IL Z fL
Monitoring QRecovery tt fL
ection Well: fL fL
quifer Recharge QGroundwater Remediation
13I.SANDIGR,SY
quifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPPLACEMENTMETHOD
Aquifer Test [3StormwaterDrainage �f7 fL Z fL } Z-.Uodxperimental Technology Subsidence Control 0- fit
Geothermal(Closed Loop) 13Tmcer "20.DRILLMG-IACs attfi mtlal+ee 'f1 -l
FROM TO DESCRIPTION(color,hardness,wil/rwk sin,et'-)Geothermal(Heatin 'Coolin Return) Other(explain under#21 Remark)
O fL t fL bpow►t Q �i.
4.Date Well(s)Completed: Well ID# fL ZZ CL brObvll w J"C J�!!/(f
It. fL
Sa.Well Location:
1%bef4 M Wk A fL fL
Facility/Owner Name FacilitylD-(ifapplicable) tt- fL
7-20S Satkrididler JU Corolla 27 f V It. ft. �-e .
Physical Address.City.and Zip R ft.
Curry+uGk 01 7Aoo/oa/r000 2 '
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Information atlOPl {DfQv@$SICI I illi#
(if well fiel(L one lat/long is sufficient) 22.Certification: D�r R`Seciion
3(' 31 4 t" N �s° S'i sY W �.--- 0 it SAO
6.ise)the well(s)&ermanent or 13Temporaty Signature o emfi ell Co ctor Date
(ar
13y.signing this form.I hereby certifi that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: UR es or [3No wii4 I5A NC.AC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well ronstruction information and explain the nature of the ropy of this record has been pros ided to the well owner.
repair under#21 remarks section or on the hark of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You ma} 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.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: aOIL A) 24a- For All Wells: Submit this form within 30 days of completion of well
Nor multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below'top of casing: �I (ft.) Division of Water Resour-ces,Information Processing Unit,
Ifwater level is above casing,use" "tt-- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. V (in.) 24b.For Iniection Wells: In"addition to sending the form to the address in 24a
above, also submit one cop) of this form within 30 days of completion of well
12.Well construction method: tItttEl� construction to the following:
(i.e.auger.rotary.cable,direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY- 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 I Method of test: (.a P-aw 24c.For Water Sunmly&lr jecdon Wells: In addition to sending the form to
1�- the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: T1 rL Amount: t� oZ 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