GW1-2021-04628_Well Construction - GW1_20210510

WELL CONSTRUCTION RECORD Q W-1) For Internal Use Only:
1.Well Contractor Information:
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Well Contractor Name ,.el�,`"�' FROM TO DESCRIPTION
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NC Well Comrac Certification Number A
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FROM TO D TIUCI04M MATERIAL
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Company Name f� � _
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16.INNERCEISINGOR�,3'[JBING: Clad d
2.Well Construction Permit#: lr goG L/L" 0 3 FROM TO DIAMETM TIHCXWM MAT1DtIAL
List all applicable well construction permits rLe.UIC,County,State,Variance,etc.) tit. f• in.
3.Well Use(check well use): ft in.
Sc.
Water Supply Well: gFROTO DIAMETER SI OT SM TMCIMM MATERIAL
❑Agricultural ❑Municipal/Pubiic ft. in.
❑Geothermal(Heating/Cooling Supply) l3�dential Water Supply(single) fL is
❑Industrial/Commeroial ❑Residential Water Supply(shared) .. 0-
T❑ltri ation ❑Wells>100000 GPD TO 4 MATERIAL EMPi ACFJt�lv1 oD/kAMOUNT
Non-Water Supply Well: aft D�e O ure .❑Monitoring ❑Recovery ftInjection Well: ft.
❑Aquifer Recharge ❑Groundwater Remediation r ;
GRAt�E1. CCK? e❑Aquifer Storage and Recovery ❑Salinity Barrier TO MATERU EMPLACEbffi�TMETHO!D
❑Aquifer Test ❑Stormwater Drainage❑Experimental Technology ❑Subsidence Control fL
❑Geothermal(Closed Loop) ❑TracerING•I tTO DFSCREMON color Inrdn willmNr eta❑Geothermal eatin Cooling Return ❑Other( lain under#21 Remarks OfL ft. �
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4.Date Well(s)Completed: 0 Well ID# a ft a O ft. C k 1
5a. ell Location:'t 0% 30 ft-
4
, e t'� 1-V Yv,a S' ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft it
/soI �_aA �1 ft. ft.
Physical Address,City,and Zip ft' f
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21i RElGIARKS -s tsx 774cr rt7
County Parcel Identification No.(PIN) S;: e�... Gr^ e✓m ✓Q S de
5b.Latitude and longitude in degrees/minutes/sewnds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
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6.Is(are)the well(s): Bfe—rmanent or ❑Temporary Signature of Certified well CoAtractor 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 erasting well: Oyes or MNe o 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known 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 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 I GW-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: 3o I (fG) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ijdifferent(example-3@200''and 2@1001
10.Static water level below top of casing: // (ft.) 24s. For All Wells: Original form to Division of Water Resources (DWR),
Ijxarer level is above casing,use"r+"_ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
il.Borehole diameter V (in.) 24b.For Injection Wells:Copy toIDWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12 Well rnnstrnetion method: 24c.For Water Supp and Open-Loop_Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental ly ealth department of the comity where'—flleed
FOR WATER SUPPLY WELLS ONLY: / / 24d.For Water Wells Droduciina over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gam) Method of test: /d W Pemut Program 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 64-2018
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