GW1-2021-05447_Well Construction - GW1_20210527

\ WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: / c
34-WATER:ZONES 7.
w,. .._
FROM TO DESCRIPTION
Well Contractor Name ft. ofi .2,
& fL
NC Well Contractor Certification Number 15:-:OUTER,CASING:for milli eiaedrells ORI IIYER.►fif Isle '' "` ''
FROM TO DIAMETER THICKNESS MATERIAL
Fro n-' W e i l C O ft I J & I G in. `✓
Company Name
GW— 0 `, Q I 1 p 0 "2O- ;16=INNER CASING)LOR.. ING,
2.Well Constriction Permit#: —! Q"!Q FROM To I DrANELTFat IffiCKNEss MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft rn'
3.Well Use(check well use): f, h' in.
Water Supply Well: 17:;SCREEN .
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural []M ipal/Public U ft & in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft
Industrial/Commercial Residential Water Supply(Shared)
=;18:-GROUT_
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O fa d fl,_
Monitoring ;Recovery & fL
Injection Well:
ft ft
Aquifer Recharge 13Groundwater Remediation
Aquifer Storage and Recovery []Salinity FROSMND/GRTO PACK MATERIAL
TLL I Le EMPIACEMENT M 01)
Salini Barrier
Aquifer Test 13Stormwater Drainage fit. &
Experimental Technology Subsidence Control & ft
Geothermal(Closed Loop) Tracer 20:_DRILLING LUG attach eddra6niil'sheets if recess
Geothermal(Heatin ling Return _,Other(e lain under#21 Remarks) FROM TO DESCRIPTION color,trardncss,soivreck
C sae,etc.
0 fL ft O .$'
4.Date Well(s)Completed;� Well ID# ft ►� fL (' Q
59.Well Location: a fL SO fr. f"17
pay � w f
aGy►�e-S /.�L/ �,tC"84-'SO� ft ft S �r>�� � '",o�
Facility/Owner Name Facility ID#(if applicable) ft ft
MG k 91-a4 .S C.tr e ft. fL
Physical Address,City.and Zip 1 f ft. ., ,, 4i 1�PC^i SS4Cet,U Zl)
W C�`P 21`REMARKS . ' L:OD► _:;'
County Parcel Identification No.(PIN) al !V S d
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: P
(ifwell field,one lat/long is sufficient) 22.Certification:
N W- I — &,a=
6.Is(are)the well(s) 'Permanent or OTemporary Signature of Certified Well Co ctor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or 13No with 15A NCAC 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 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: b L 00 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@100') construction t0 the following:
10.Static water level below top of casing: O (ft) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use L
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (ii.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: /
/ above,also submit one copy of this"fort within 30 days of completion of well
O construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division 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: OIN 24c.For Water SunDly&Iniection Wells: 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: Amount: I' completion of well construction to the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016