GW1-2021-05931_Well Construction - GW1_20211115

CTION RECORD(G'W-1) For Internal Use Only:
r Information:
^► 4^y
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FROM TO DESCRIPTION
ell Contractor Name
iL
ft.
NC Well Contractor Certification Number 15c '' tpl tiiGlii' gIt I:IhTE " ' b11"
FROM TO DIAMETER Tfujcla m MATERIAL
Pool via), ' P�►p 60, ft. g ft. la. ID v e
Comparry Nam ; ,.,
P q o a �9 t ,
2.Well Construction Permit#: A r FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well canstraction permits 0.e.UIC,County,State.Variance,etc.) ft. ft �•
3.Well Use(check well use): %
Water Supply Well: FROM TO 2, DIAMETER SLOT SIZE ..THICKNESS MATERIAL
Agri�� unicipaMblic ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial ®IResidential Water Supply(shared) •
Irri on FROM TO MATE EMPL.ACFMiENT METHOD&AMOUNT T
'Non-Water Supply Well: ft aC ft- . M 11 �q v'
Monitoring - Recovery it ft
Injection Well: ft, ft.
Aquifer Recharge 13Groundwat�er Remediadon
Aquifer Storage and Recovery Salinity Bonier FROM TO MATEATAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft. f1
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer
FROM TO DESCRtP77ON color,hardn soNrock in dc.
Geothermal(Heating/CoolingReturn .Other(explain under#21 Remarks � � 0 it.
4.Date Well(s)Completed: « "a Well ID# 10 ft. S00 ft. re �
ft. ft.
5a.Well Location:
Po h La N ft. ft -
Facciliity/OwnerName Facility ID#(if applicable) ft. ft.
`&L (Rr6]@h0. ft. ft. DMSECBMI
Physical Address,C,iityy,,and zip ft. ft. INFORROMTK
countyy Parcel Identification No.(PIN) e e v e 's l e h
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwall field,one lat/long is aut£cient) 22.CertiH on:
x W
6.Is(are)the wells) Permanent or Temporary SigoatWofCertilled Well Contractor Date
By signing this form,1 hereby cert6 that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or No with 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
1f 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 thisform. 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,�n,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1- SUBMITTAL INSTRUC1TOxS
9.Total well depth below land surface: �� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lfd{ferent(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing: -L 0 A) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use.+" 0' 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:- _ 4-_(in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
r• ro4y ry above,also submit one copy of this forum within 30 days of completion of well
(Le Well construtitio method: construction to the following:
(i.e.auger,rotary,cable,, method:direct etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: I Q 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 0 Method of test VJ 24c.For Water Suooly&Ipie on 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: ' completion of well construction to the county health department of the county
where constructed.
17 m GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 222-2016