GW1-2021-04577_Well Construction - GW1_20210429

W r,1.,L l:V1N J 1 KU k_11U1N Kh,l UKU ((i W-1) For Internal Use Only:
1.Well Contractor Information:
i
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Well Contractor Name �0 FR TO �DESCRIPTION+
5 �ft. EOftt.
ft.
NC Well Contractor Certification Number 'P/ OG�\O �S:OUTER CASING foicmulh.cs"sed ryellsORgLI3VER ifs licable i°c `?isr
FROM TO1 DIAMETER I THICKNESS MATERIAL
+.I ft �0 ft. I 'Z m. P
Sal`e-6 V�
Company Name �� .A , , x
\� �16.�*"_ER CASINO�OR�II[7BIlyG": 'eoti ermaliclose� 69b
�ls�s ao ioo _ �...._..
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.$CREE.N - t r..,.ai ° +t: �Fv 2t a xlI ZZ7
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public o gbft. Q 6 ft. a in. dl b o u v
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. tt. in.
Industrial/Commercial Residential Water Supply(shared)
'•.1 S:,GRO.U'I''
IITIgaL10'' FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Wa "pply Well:
...p
i Monitoring Recovery �Q ft. O ft. S N
Injection Well: cy
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salini Barrier 19.aSA1VD/GRAVEL:PA'CK t-a `licable ;
q g r' FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStornwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20;pRILLING_hOG attach a`d'ditional sheets it;necessa':
FROM TO DESCRIPTION color,hardness,soilfrock type,grain size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. ft. T°! �,, �, �►_ _/
4.Date Well(s)Completed: '3_30' ell ID# ft. _ d ft. ' «^•�L
5a.Well Location: ft. :1® ft
5 I n Pn r--, / 121\ 3011. C) ft.
Facility/\�ner Name /� r Facility ID#(if applicable)ft. 6 S ft. G(
r lc, 'Q ��L1�i rqn-oul lI L► , D 261. ft. C
Physical Address City and Zip CICAA
-1ZEMARKS
1
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r.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification.•
N W
6.Is(are)the well(s) ermanent or OTemporary Signature off ei'fified Well Conhac Date
By signing'thls f/ortii;,1 hereby certify that the well(s)wqs(were)constructed in accordance
7.Is this a repair to an existing well: DYes or �i No with/SA�k&;C 02C`.0100 or 15A NCAC 02C.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#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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 16 SUBMITTAL INSTRUCTIONS
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 tJ200'antd 22 t@r 100') construction to the following:
10.Static water level below top of casing: of (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: q (in.) 24b.For Infection 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: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) _
Di,Asion.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: r 24c.For Water Su6yly&Infection(Wells: In addition to sending the form to
the address(es)-At ove,'also submit one copy of this form within 30 days of
13b.Disinfection type: 1� Amount: 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

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