GW1-2021-04508_Well Construction - GW1_20210429

. iZy 2�r�u? k� .Y•�i...
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well-"nutraetor Information:
44.awATER . .zoNhs . .,:;,:
Well Contractor Name r FROM TOI DESCRiffl0N
6 l Z
NC Well Contractor Certification Number riL G ft.
15.OUTF.R:CASING f6F&filti;6sed:wellb'ORZINER is""Ueiible
/ FROM TO DIAMETER THIC[QIESS MATERIAL
+f�ft y/ It. in. 3�
Company Name
r 167II�MWCASING OR-TUBING: 'e6theimsl'"ii!aoo' ?>=r:'ui: s'e ; ;i•':-:>;`
2.Well Construction Permit#: 7 FROM TO DIAMETER T®CIINFSS MATERAAI
Listall applicable well construction permits(i.e.In ,County,State,Parlance,etc.) ftL ft. In.
3.Well Use(check well use): ft. ft. tn.
Wat
Agricultural OMunicipaVPublic TER ter Supply Well:
FROM TO DIAMETERS SIZE THICKNESS MATERIAL f
0 ft ft.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
IndustrialCoaunercial DResidential Water Supply(shared)
Lion FROM TO MATERIAL', EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 32 ft. ii t7 J
Monitoring DRecovery fc ft.
Injection Well:
:)Aquifer Recha e � h'Recharge E)Groundwater Remediation
Aquifer Storage and Recovery s,19.a5AND/CRAVEI:PACK if'a tieibii
Q rag Very �SaliilltyBarrier FROM TO MA7ERGL. EtHPLACEMENTMETNOD
_ Aquifer Test OStormwater Drainage & I ft
Experimental Technology OSubsidence Control ft it.
Geothermal(Closed Loop) Tracer .2&'DltMLi 4G LOG atfikh idditiou6lMW64t I,r,'•
Geothermal FROM TO DESCREMON eotor kard sow-ek_. etu
(Heating/Cooling Cooling Return) . Other(explain under#21 Remarks)
4.Date Well(s)Completed:_y�s= Z j Well ID# ft `/}-�
5a.Well Location: s ft 7 d� ft. $ i
,D 4Jh of ,Lrrd_,An Tr l
IL
ft.
Facility/Owner Name Facility ID#(if applicable) ft f.
ft ft
Physical Address,City,and Zip ft. ft
€2l.REWARiCS`', a Y.i�.;.w i�
e) �l
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrceslminutes/seconds nr decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: Dw
3J_d3r21. --/3zl tN _,90*3? ' 7, 3.5'03't W
6.Is(are)the well(s)afrermanent or Temporary Si ore ofCcrtifice Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.1s this a repair to nn existing well: E)Yes or K3Ko with ISA NCAC 01C.0I00 or ISA NCAC 02C.0200 Well Comtruction Standards and that a
If this is a repai'fill out known well construction information and explain the nature ofthe copy ofthis record hats 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:
S.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: �+ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 700 (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
Formuiriple wells list all depths rfdWerent(example-3(d/100'and 2(a]M construction to the following:
10.Static water level below top of casing: eZ (fL) Division of Water Resources,Information Processing Unit,
Ifwater level is above caring,use"+^ 1617 Mail Service Center,Raleigh,NC 276"-1617
11.Borehole diameter: ul A/ (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:
(Le.auger,rotary,cable,direct push,etc.) Construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: nn /� y 1636 Mail Service Ceni er,Raleigh,NC 27699-1636
13a.YIeld(gpm) le Method of test: �F• . 1G T 24c.For Water Supply&Iniection dWells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection.type: C hlo r:tl a Amount: O z, completion of"well construction to tiie 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
I