GW1-2021-07403_Well Construction - GW1_20210921

\ WELL CONSTRUCTION RECORD(GA-1 For Internal Use Only.
I.Well Contractor Information: t
fAI d L'O 14 WA1 ER 7.oN1SS i
` D �n PROM To DESCRIPTION
Well Contractor Name ft.
% , r�V� ft. R
NC Well Contractor Certification Number Q e�"oq ;s'oUTER'CA51NG:fpr_muttix � + 08
COL¢•'O� FROM TO DIAMEI'F� MATERIAL
y'/arttt Wet/ o ,_>,O�p�,e��` ft 0 f< ;a tar
Company lzame
`�t I 16•II3IVSRGASING
2.Well Constriction Permit#: '� �S' EOM TO D� �
List all applicable well construction permits(ie.UIC.County,State,Variance,etc.)
ft ft in.
ft. ft. in.
3.Well Use(check well use):
water SupplyWell: FROM
FROM TO DIAME7'Fdt 3LOT SIZE TRICKINESS .'IHe1TPdUAL^�,
gricultural 13MtmicipaVPublic 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) QAe�dential Water Supply(single) fe ft. in.
Industri&Commercial Residential Water Supply(shared) 18.:GitOUi
litigation FROM TO MATERIAL EMPL4CEA FdNT METHOD&AMOUNT
Non-Water Supply Well: ft. dv ft 0
Monitoring Recovery ft. fa
Injection Well:
ft ft
Aquifer RechargeGroundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FRO�/G TO PAS tMA"TEn1A� EMPLACEMFavr n�IHOD
Aquifer Test E)Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.•DRILLIIVG LOG-attach additional,slieeta lI.
Geothermal(Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION eoloq dardaesa,eavreek etc
ft. tL
4.Date Well(s)Completed:`�,Well ID# f- t10 ft- Ci O
5s.Well Location: —at)& Jr It. saw
Me - t'nSPrl �n 'nveSLrnCott SG ft.
Facility/Owner Name Facility ID#(if applicable) h' ft.
6\a F1 e#-ft Ls\CL & &
Physical address,City,and zip �— ft. fl.
21,REMARKS
County Parcel Identification No.(PIN) e 1 r I✓e Aare
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient)
22.Certification:
N Wza L
6.Is(are)the well(s) Permanent or 13Temporary Signature o Certified VVell Con for Date
By signing this form,!hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or [afrowith 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
ff 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 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:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �Gy (ft) 24a. For All Wells: Submit this fort within 30 days of completion of well
For multiple wells list all depths if different(example-3@200"and 1@100,) construction to the following:
10.Static water level below top of casing: (ft-) Division of Water Resources,Information Processing Unit,
lfwater revel is above casing,use'•+• 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in,) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12 Well construction method: 'j QI'4 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
13s.Yield(gpm) Method of test: 24c.For Water Supply&Injection 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.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016