GW1-2021-07445_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 7
1.Well Co tractor Information: �
/1�
Well Contractor Name ° FROM I i0 DESCRITION
NC Well Contractor Certification Number
f n �j� �� �GGe'`,Q(� 5*YOCJTE1t'GASII�tG'fuFiiutti' f�elfs`OR°I:IlVER: fs" lic5ble
�^'i s��/� '"� �CQ- ��A�OJ FROM TO DIAMETER THICKNESS MATERIAL
fL ft in ��
Comparry Name ,�.� �.� � '©D
"� �1'6.�.11YNE12 G;AiS1�fQG�URf,•T;[JBING`_euthermslelosed ID'•` �' �:�
2.Well Construction Permit#: QV' � ✓ 2..Z��� FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits C,County,State,Variance,eta) fL M
3.Well Use(checkwell use): IL tt in.
x117i1SL'RE9NA11119S W-40 .. : ..
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS ^I MATERIAL
Agricultural DMunicipal/Public B % M in
Geothermal(Heating/Cooling Supply) 18kesidential Water Supply(single) R n. in
Industrial/Commercial Residential Water Supply(shared)
Irri atiOn FROM I 70 MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0tt n -hi t T bc y
Monitoring Recovery ft %
Injection Well:
i Aquifer Recharge Groundwater Remediation ii9 z5AND/GRA�EIIPACK`to' ca
ff. tt
�
__Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL, EMPLACEMENT METHOD
1 Aquifer Test ®Stomlwater Drainage M tL
Experimental Technology ®Subsidence Control % ft.
__1 Geothermal(Closed Loop) ®Tracer 1,4h9iti 16re"j'Vvfi ...
FROM TO DESCRIPTION color ha es sollfrock in etc
Geothermal(Heating/Cooling Coolin Return Other(explain under#21 Remarks
t
a %
4.Date Well(s)Completed: Well ID#
5a.Well Location: R s D R `;.7
Facility/ wner Name Facility ID#(if applicable)
Physical Address,City,and Zip ft. tt
County Parcel Identification No.(PIN) e AVe SjVJ Uje O.t 6- 11C
5b.Latitude and longitude in degrees/nitnutes/seconds or decimal degrees: 8/
(ifwell field,one lat/long is sufficient)
�( 22.CertfScation:
N "_D,7 a2f5G W 2� :6141
6.Is(are)the wells)J3Permalu nt or [I Temporary ' Signature of Certified Well Contractor Difte
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: MYes or oNo with I SA NCAC 02C.0100 or 1 SA NCAC 01C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. I
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.
dolled_ 0 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 403 ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(a3200'and 2®100) construction to the following:
10.Static water level below top of casing: LD (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: W (ln) 24b.For Infection Wells: In additi In to sending the form to the address in 24a
12.Well construction method: _ !(it aTAr above,also submit one copy of this tort 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
13a.Yield(gpm) Method of test: A lw 24c.For Water Sllnniv&Infection!Wells: In addition to sending the form to
�f ` the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1 r 0 Amount: completion of well construction to the'camty health department of the county
where constructed. i
�I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016