GW1-2021-07451_Well Construction - GW1_20211006

WELL'CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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e
..,��",'�" �, ;r4.;, Ama•.R'zoNEs R. ,
-� FROM TO DESCRIPTION f
Well Contractor Name sW
ft. Z TO ft M,
(� rL IL
NCWeIIContract Certificat'anNttmber `?�n�' �0� ��v `
Y5 OIITER;CTOAIING,tdr n `iiltl;> ivells';iOR•I INER 1ta"IlFlittle
FROM DIAMETER I THICKNESS MATERIAL
Company Name .0 ft S2 ft b v in.'i
/� , I /7 ,!' 1bt;INNER';CASING.(1B:TUBING:' eotherma!closed-hio
2.Well Construction Permit#: y (/" �`fy �^�(/ FROM I TO DIAMETER it THICKNESS I MATERIAL,
List all applicable well construction per its(i.e.U1C,County,State,Variance,etc.) iL ft in.
i
3.Well Use(check well use): rL ft in.
Water Supply Well: 17:SCREEN
FROM TO t DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
Agricultural QMunicipaVPublic 0 ft ft in.
BGeothermal(Heating/Cooling Supply) &yResidential Water Supply(single) ft. ft. in
Industrial/Commercial Ei Residential Water Supply(shared) <;;18,GROtIh
- - -
Irrr ation FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft s/ 6
Monitoring ry EL
Recove 2t�
ft
Injection Well:
tt M
Aquifer Recharge QGroundwater Remediation
SAND/GRA�'EL':PACK"tf6 -hcable "
Aquifer Storage and Recovery oSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. M
t Experimental Technology OSubsidence Control ft. M
I
Geothermal(Closed Loop) DTracer 26.-DRILLING LOG'.:iitti li sidditi6nil:ebeetsjf necessa
Geotliennal(Heating/Cooling Retum) .. Other(explain under#21 Remarks) FROMI TO DESCRIPTION color,baldness,so Wrack fain size,etc
M i ft ^/
/
4.Date Well(s)Completed:`7G�;k Well ID# ' rL 7 it
`J� �
5a.Well Location: fL Jo-7 ft Cs+vT` i
p� ft. rL T`
Facifity/Owner Name ,t �Facility 1D#(if applicable) ft. N
W 0� �i?/ ��l0-, Tu5 U �i�ri ft rt.
Phvs'cal Address,City,and Zip ft. ft
���(County �j-
Parcel Identification No.(PIN) l �v� a�i "f �aS Nam/�n 60 ^
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: u°f
(—we eld one
Chat/long its su—ffi7cient) Q �(/ 2 22.Certification:e
6.ls(are)the well(s);DPer manent or Temporary Signature of ertified Well Contractor Date
By signing this form,/hereby certtry that the wells)tvas(were)constructed in accordance
7.Is this a repair to an existing well: DYes or,9No with 15A NCAC 02C.0100 w ISA NCAC 02C.t/200 Well Construction Standards and that a
1f 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 6n,ner.
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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
�� SUBMITTAL INSTRUCTIONS
Q.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Far ntulriple wells list all depths if different(example-3@200'and 2Q100') construction to the following:
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10.Static water level below top of casing: (ft.) Division of Water Resources,In Processing Unit,
If water level is above casing,use
/"+"r� 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (p (in.)
24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: �(f l/ IbPVy 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
13a.Yield(gpm) /0 Method of test: �,y� 24c.For Water Supply&Iniection Wellsa: In addition to sending the form to
�/ the address(es) above, also submit one copy of this form within 30 days of
1 13b.Disinfection type: f t r r/ Amount: I 16f 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 i Revised 2-22-2016