GW1-2021-04554_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: �.
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FROM TO DESCRIPTION
Well Contractor Name
NC Well Contactor Certification Number APR --.OUTER?CAsn�rs ftnttlaaeifl`
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Q e Ro n~f W t l 1 1 C-0 �r y�g�$S R( oM TO DIAMETER THICKNESS MATERIAL
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Company Name /J� l`)1 (/�\ (,,SDI f/vG�C.CCTJ"�//^�/b(£`y'Jy/��1 cJ4( '.✓
l3 �^' V tJ\V— • , l F6.11�1�1'iRyL''A31i�lTQ IJ4ME _
2.Well Construction Permit#: I�toM To DIAMETER TffiCIiTiFSS MATERrAi.
List all applicable well construction permits(Le.UIC,County,State.Variance,etc) ft. fL
3.Well Use(check well use): ft- R'
1 la:1CREEN
Water Su
PP Y Well: FROM TO DIAMETER I SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑ cipaUPublic ft, e. in
❑Geothermal(14cating/Cooling Supply) ❑Residential Water Supply(single) fL g. in.
❑ludustrial/Cotnmerefig ❑Residential Water Supply 1 shaved =,
rlIffioation ❑Wells>100,000 GPD FROM TO MATERIAL El1fl'r ACEMENT tWMOD&AMOUNT
Non-Water Supply Well: b ft tt Ole t 6we-
❑Monitoring ❑Recovery fL ft.
Injection Well:
fL tt
[]Aquifer Recharge ❑Groundwater Remediation
,A9.SAND/GRAVVLWXCK' e, 014 r e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL E U'LACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control fL &
❑Geothermal(Closed Loop) ❑Tracer 20:DRII:isING'LOG,ittacha`daitlonii:abeetinifs`" �ter_. ?
❑Geothermal eatin Cooling Return ❑Other(explain under#21 Remarks FROM TO DESCRIP170N color mrdn wtYroek etc.
o ft- 3 fL � sue-
4.Date Well(s)Completed: Well ID# tt. a 0 & C— Q
Sa Well Location: OfL 'S4w
0 G r`t3n Pr
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Facility/Owner Name / Facility ID#(if applicable) fL fL
� a �ev1 ne�S c�Gy fL ft.
Physical Address,City,and Zip ft. M
WQ K� 2L REMARKS _
County Parcel Identification No.(PIN) J �e
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N �r W -�
6.Is(are)the well(#): 9lrermanent or W1'emporary Signa of Certified wet Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repay,fill out!mown well construction information and explain the nature of the 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 GeoprobeMPT 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 GW-1 is needed. Indicate TOTAL NUMBER of wells ( 'See Over'in Remarks Box).Yoiimay also attach additional pages if necessary.
filled' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 01 Ll
( ) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 rQr 200'and 2@1001
10.Static water level below top of casing: (t) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ijxnter level is above casing,use"+� Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
1L Well construction method: a 24c.For Water Supply and Opeo-I 1 op Geothermal Return Wells:Copy to the
(le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where` installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Producine over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 0 Method of test: 0)0)),A) Permit Program,1611 MSC,Raleigh,'NC 27699-1611
13b.Disinfection type: 4TAmount: !h
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2018
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