GW1-2021-04235_Well Construction - GW1_20210419

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Well Co Name FROM TO DESCRIPTION
u cur g©R l d7 d ft. f--
. /1 ft. ft.
NC Well Contractor Certifica'on Number r p0
FROM IER CASING:torimattl cued Was;ORLINER: ,tt Heitile
f e' Llgy, FROM TO DIAMETER T19"MSs MATL+RIAL
ft.
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s Com/panyName ' .Y6 INNER;CASING OR TUBING;,.eethermi--da n L, k a '
2.Well Construction Permit#: N 1 ��/���� g 7 FROM TO DIAMETER THICKNESS MATt3tw.
List all applicable wit construction permits(Le.UIC,County,State Variance,etc.) ft. R' la
3.Well Use(check well use): fi R tm
Water Su Well: .]7:SCREEN
PPIy mp�
DIAMETER SLOT SITS+ THICIQVFS3 MATERIAL,
DAgricultural ❑Municipal/Public 1� in
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ln;
❑lndustrial/Commercial ❑Residential Water Supply(shared) j18-GROUT ;
lion ❑Wells>100,000 GPD FROM I TO MATERM, EMPLACEMENT'N=10D&AMOUNT
Non-Water Supply Well: d fL ft j �//v
❑Monitoring ❑Recovery It. ft. e
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation ,� w ;f
19.SAND/GRAVEI:'PAGKi a "IIcitile � -`f,:: .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL / EMPLACEMENTMEMOD
❑Aquifer Test ❑StormwaterDrainage 7 L Cle fl 1 1 l✓✓F� .
❑Experimental Technology ❑Subsidence Control fL 9
❑Geothermal(Closed Loop) []Tracer 20.DRIL ING�I:OG'atiicti;sddttloa6l ehesti if;neai
❑Geothermal(Heating/Coolin Return ❑Other( lain under#21 Remarks FROM TO DESCRIPTION color tvada aoWsoek as
fL It.
4.Date Well(s)Completed: — o-21 Well im ft. ft.
5 Well Location: fL fL
R'yen�ticf-
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Facility��/Owneer/r'Name / ,-gym F'accilityM#�(iifapplicable) R' / �a r
iie (7Ak Woof/ r t/l,nkrolle . tL / fL
Physical Address,City,and Zip ft. fL
County Parcel Identification No.(P1N) 1�t�Gr1�' `'- epr t0P1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficietg) 22.Certification:
N ��"12? ��� W V`�',,0 ten('®-2 i
6.Is(are)the well(s):` ermanent or ❑Temporary SWatue o 'ell Contactor Date
By signing this form,I hereby certify that the»rll(s)xns(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or )Mo 15A,''CAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
If this is a repair fill out known well construction information and explain the nature of the of this record has been provided to the xrll 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 construction info
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach.additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: —(fL)
For multiple wells list all depths ifdif ferent(example-3Qa 200'and 2@100) Submit-this GW-1 within 30 days of well completion per the following:
24a. For AB Welts: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: % Tt (ft.) Information Processing Unit,1617!MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+/" 4.
II I I 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borebble diameter: (in.)
Program,1636 MSC,Raleigh,NC 27694-1636
12.Well Instruction method: 24c.For Water Supyly and O en-Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health epartment o the county where mstalled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producine over 100,000 GPD:Copy to DWR,CCPCUA
/�, Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) "/D Method of test: l
t
13b.Disinfection type: T H Amount: G�
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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