GW1-2021-07324_Well Construction - GW1_20211006

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WELL CONSTRUCTION RECORD(GW-11 For Intemat Use Only: ;
1.Well Co.yactor Informon:
v 14 �:14.'VvA'CkRZO
Well Contractor Name FROM TO DESCRIPTION
30
ft ,
NC Well Contra for Certification Number `�\ S� tt
//A// ///I /,!�// //' 'F ft ft rn• 'THICKNESS
ifii""Ncl ..,,...,.
•V F f/' vle klell�. �'t\�ECP�'� 'FROM�TEII.'C(T�OINfil.for"M DIA' r Rem THIf.C(K'NESS MATERIAL
Company Name Q' J 1 �OQ LI
/ /•, .-,/y. ^� !9 �:-6i;1NNER"'CASING OR;TUBING eothermal closed-ldo ' -" '
2.Well Construction Permit#: C'V�I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction perm is(i.e.UIC,County,State,Variance,etc.) ft ft in:
3.Well Use(check well use): ft It.
Water Supply Well: 17::SCREEN, ,
FROM TO DIAMETER SLOTSIZE THICKNESS MAI•ERWI,
Agricultural QMunicipaVPublic 0 ft ft in.
Geothermal(Heating/Cooling Supply) rResidential Water Supply(single) n.
Industrial/Commercial Residential Water Supply(shared) lti GROUT:
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: © ft. ft
Monitoring Recovery Ct ft J
Injection Well: I
Aquifer Recharge Groundwater Remediation ft ft
;'`1WSAND/GRAVEL PACK_it6Iinlicablh
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [DStormwater Drainage ft ft
I Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) E Tracer 20:,D1tIhL'1NG;LOI"t;attacNadditionalsNpe
ts;rf n .
� Geothermal(Heating/Coolin Retum) Other(explain under 921 Remarks FROM To DESCRIPTION(color,hardness,W11roek ' rain sire,etu
ft. ft K
�t f
4.Date Well(s)Completed: Well ID# / rL ft
5a.Well Location:: / ft ?2
v/dwel ` H ft. 7Z
Facilitv/ wner Name nn Facility ID#(if applicable) ft ft
A�i /TIC �40� ff. ft
Physical ddi ss,City,and Zip ft. ft
ppWoke31i REMARKS
County Parcel Identificatioi
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `
(if well field,,one lat/long is sufficient) 22.Certification:
3So7—L3 N
/ KeUC...u., T6.Is(are)the well(s) ermanent or Temporary Signature of Certified ate
By signing this form,1 hereby certify that the wells)ryas(ivere)constructed in accordance
7.Is this a repair to an existing well: OYes or iV0 ivith 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a
If this is a repair,fill out known well construction information an explain the native oJthe copy of this record has been provided to the well oiwter.
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
Z? SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Z (tt•) 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 to the following:
10.Static water level below top of casing:__ !�� (ft.) Division of Water Resources,In!tormation Processing Unit,
1/ivoter level is above casing,use'-�" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �D t '(in.) 24b.For Inlection Wells: In addition to sending the form to the address in 24a
12.Well construction method: a(ir 0 Lv above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.)
construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i / �/ I
13a.Yield(gpm) 12 Method of test: &0 t J 24c.For Water Sunply&Iniection Wells: :In addition to sending the form to
i I{6 „ I/ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: L 1� completion of well construction to the co tinty health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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