GW1-2021-07440_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD (GW-1) ' For Intemal Use Only:
1.Well Contractor Information: � �✓ _
I1n�,\ 14.WATJERZDNES:e. . .s,
Wei Contractor Name (�( �.- r� M TO DESCRIPTION I
CaN
X, It. fL
NC Well Contractor Certification Number
///��� �.(�3- �cJ `,"•15�O't1TER CASING;for mirth=eased 3vells x t>L]NER`df ii
W Pxi/e !- .��� y /r,p��t�`� p�� PROM TO DIAMETER THICKNESS MATERIAL
III "L W /I l/"°' IL fL
Company Name
16;1NNER:CASING OR;TUBING euthirm it elokil-400
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS IMATERIAL
List all applicable well construction permits(i.e.UIC,County,State,variance,etc.) 6 to
3.Well Use(check welll use): IL ft in.
17.'SCREEN
Water Supply Well: FROM TO I DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipaVPublic 0 Pt ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fit. R. in.
ndustrial/Commercial DResidential Water Supply(shared) :18,GROUT.'.
Irri ation FROM TO MATERIAL ED7PLA EMENT (ETHOD&AMOUNT
Non-Water Supply Well: n. d ft )� A wr
Monitoring ORecovery n. ft.
Injection Well:
�
Aquifer Recharge QGroundwater Remediation
!i19:',SAND/G ft. ft
RA$EL`PACIC ita"licablc
f Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage n ft.
Experimental Technology OSubsidence Control n. rt
QGeothenmal(Closed Loop) DTracer Z20abRILL1NG.LOG`. itmchiadiNHonal`aNeets;dnecessii
Geothermal(Heating/Cooling Return) i Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiv—k type,gnin sim,etc.)
312 561z
4.Date Well(s)Completed: p-�r Z r Well ID# n- - ft Al v
5a.Well Location: ft. fL
s & / n. ft
Faci ity//OwngrName Facility (ifepplicable n- ft.
IILL////�I ft.
Physical Address,lity,dnd Zip fL it
l� 21s REMARKS s
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certificatr'tyr
N e��a W /
v.ls(are)the well(s)OPermanent or ._Temporary ignature of Certified Well Contactor Date
��,_ By signing this form,I hereby certify that the rvell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or 0<o with I SA NCAC 02C.0100 or 15A NCAC 02C.0200 well Construction Standards and that a
If dais 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 onn er.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
3.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: !0� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
ror multiple wells list all depths if different(example-3 r200'and 2@100') construction to the following:
if Stalk water level below top of casing: O (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"(" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: v (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
�� above,also submit one copy of this form within 30 days of completion of well
Y(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
13a.Yield(gpm) C- Method of test: 'U Y 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: I L completion of well construction to the county health department of the county
where constructed.
Fonn G W-l North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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