GW1-2021-07449_Well Construction - GW1_20211006

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only. -
!.Well Contractor Information: e In
r"pl h V' LJ nC1t1` :J WATE9 ZD
Well Contractor Name v t TO DESCRIPTION
25 �CZ Q V g�R an ,'7fL
NC Well Contractor Certification Number �trGei3O(� n' ft. I
Ot1T)IUCASING,fdi multi ciased wells OR;I INER ifii llcfrble
"'�FROM TO u ft DIAMETER to i THICK ESS MATERIAIt
Company Name 1 J 1 p`W,
'1b:1NNER'CA51NG 013 T(IB1NG' 'ebthertial closed=loo
2.Well Construction Permit//: v "" 1 `��'�Oa FROM I TO DIAMETER 11uCENESs hIATERUL
List all applicable ivell construction permits(i.e.UIC,County,State,.Variance,etc.) fL ft in.'
3.Well Use(check well use): ft ft in.:,
Water Supply Well: L7^SCREIJN =
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural MunicipaVPublic 0 ft fL in
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) tt, tt tn.
Industrial/Commercial Residential Water Supply(shared)
lSi GI3bUT
- Im ffiIDn FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C u 9a
Monitoring Recovery ft ft.
Injection Well:
fL ft.
Aquifer Recharge QGroundwater Remediation
Aquifer Storage and Recovery Salini Barrier 19`,,SAND/QRA.1 PACK:if li"livable
ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stonnwater Drainage ft
&Experimental Technology []Subsidence Control �:.I)I2IIsL1NGhOG':aHachaBdrdonalsltee
Geothermal(Closed Loop) __.Tracer othermal Heating/Cooling Return) F1 Other(explain under 921 Remarks) FROM To DESCRIPTION(1-- Iy min 5i�tt�
t J n. ft 101
4.Date Well(s)Completed: a �.t Well ID# 3 M n dt /R
a-a.Well Location: (� ( ft. I{ft � » J 1(�
� Q�� r4 �A�0.� fL ft.
Facility/Owner Name ft
Facility ID#(ifapplicable) ft
Physical A dress,City,and Zip n. ft.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
t ,
6•Is(are)the well(s) Permanent or DTem racy Signature of Certified Well Contractor Date
By signing this form,I hereby cert�that the well(s)was(mere)constructed in accordance
7.Is this a repair to an eAsting well: DY, or No ivilh 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known ivell 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 Uiis 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
1 leSUBMITTAL INSTRUCTIONS
I- Total well depth below land surface: (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths ijdifferenr(example-3Q200'and 2Q100)
construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
1(mater level is above casing,use"+7 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ��YA(� (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: `0�q';`y 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:
r
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Igjection Control Program,
i 1636 Mail Service Center,Raleigh,NC 27699-1636
[13a.Yield(gpm) �© Method of test: ID k , 24c.For Water Supply&Iniection 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: T Amount: l completion of well construction to the county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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