GW1-2021-05262_Well Construction - GW1_20210503

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Cl. ► ( L ` R Ei t\r t :14 WATERZONES
Well Contractor Name ,) FROM TO DESCRIPTION
13611. 5f` 6' r re rete irx s
231 -Aft. ft.
NC Well Contractor Certification Number 15.OUTERCASING:lair mul6bdsed wells OR LINER :a Iicable
Ru t,y i _�, �. 1 1 r` _ ' Inc. FROM TO DIAMETER THICKNESS MATEfR�IcA/L
Company Name '7'� W lam) 0 ft 5.6 R to .-Y 0 P V C
�16:24NER CASING OR TUBING eothernial closed-loo'
2.Well Construction Permit#:21110611)10 q Q FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.111C.County.State,Itarionce,etc.) fL ft in.
3.,Well Use(check well use): fir. fL
Water pply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
grtcultural ❑Municipal/Public ft. 2 in. O 1s[ P v L
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL fL in.
❑industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
[Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft. o1 'P105 C in ea 2D
❑Monitoring ❑Recovery ft. fL
Injection Well:
ft.
❑Aquifer Recharge ❑Groundwater Remediation fL
tFROV
RAVELPACIE da"]ti hle _
❑Aquifer Storage and Recovery ❑Salinity Barrier TO MATERIAL EMPLACEMENTMEIHOD
❑Aquifer Test ❑Stotmwater Drainage tr ut° ire nn N4 i❑Experimental Technology ❑Subsidence Control fL❑Geothermal(Closed Loop) ❑Tracer 4GLOG'attiieh:addidoiilsbeetsifn❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) TO DESCRIPTION color,herdness,soitimck rain size,etc.4.Date Wells)Completed:4--Z2_2 1 Well ID# SSo.Well Location: 6 b R. co"
ft. R.
Gill'U I to !r'et 1�1lX ti �r.
Facility/Owner Name Facility ID#(ifapplicable) ft. R. a�
J2-i�D O tbetrr3t R� } DI►ve NC k36 R. R r
Physical Address,City,and Zip fL R.
WrL 21.REMARKS MAY X
County / Parcel Identification No.(PIN) A• r'1 c
l av —
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: DINR CSECi':Of1
(ifwell field,one lot/long is sufficient) 22.Certification:
35. Z61917 N - 7g= 092123 W
6.Is(are)the well(s): t?rermanent or ❑Temporary Signature of Certified Well ContractouO Date
- -- By signing this form,/hereby certify that the well(s)was ilivere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or )KNo 15A NCAC 02C.0/00 or 15A NCAC 02C.0200 Well C'onstructian Standards and that a copy
/fthis 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 rcnmrks 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 ofw•ells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: pNt'
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /e.�
(ft.) ycompletion
Submit this GW-1 within 30 days of well
For multiple wells list all depths ijdifjerenr(ecanrple-9 a��00'and �l 200') per the following:
10.Static water level below top of casing: i 3 (ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
f warerlevel is above casing,are":- ) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. / (in.) 24b. For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
t Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: M OTR r y 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ire.auger,rotary.cable,direct push,etc.) T county environmental health department of a county ere installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100 000 GPD: Copy to DWR,CCPCUA
13s.Yield(gpm) 3 Method of test: A M T y Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 1 04 Amount: 4 OL
Form(i W-I North Carolina Department of Environmental Qualiry-Division of Water Resources Revised 6-6-2018