GW1-2021-07456_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
r'\ ROM TO DESCRIPTION
Well Contractor Name
1 fL fL ,6 .n
NC Well Contractor Certification Number
/� �" ��(S' Q�. ;.IS.b'IP,I'.kit•,CtISINf'l:idr�jrifiltlfi d iq. •.-sOXttl!iLR if ii•'llealf(In
,AZ! 1 1 6cm i �) _ C /^7iy,�rn r FROM TO DIAMETER ! THICKNESS MATERIAL�
,i l�lY (.LC (�/�(� C C/r'N!'Y , I fL I n. 0so ,9Gw
Company Name
IR't"rASING Olt'�1NG eotlie�?iilaltldBeil=loo ,
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 1L ft in.
3.Well Use(check well use): f, H- in.
Water Supply Well:
FROM SIZE THICKNESS DIAMETER SLOT SI THICKNESS MATERIAL
_
Agricultural MunicipaUPublic 0 ft rL in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R. ft. in.
Industrial/Commercial OResidential Water Supply(shared) .18:GlfbUf
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
FInjection
upply Well: O n• ft
[]Recovery Recovery fL ft
ll: ft. fL
charge Groundwater Remediation
rage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage h• ft.
Experimental Technology Subsidence Control H. fL
:)Geothermal(Closed Loop) Tracer iO :�DRML NG T OG'ittaeir ddifionbi:siteeis ifla "' t ,
Geothennal(Heating/Cooling Return) Other(explain under#21 Remarks), FROM To DESCRIPTION color,hardn es S, 111 ck~type,gmin size,eta
n fL Top S �
4.Date Well(S)Completed:-5-3_a I Well ID# il• D
5a.Well Location:
IL
ft ft
�9(dvlo LCC.
Facility/Owner Name ^ f Facility ID#(if applicable) 0- ft.'
/e'/� I , _ /fiC U r S . fL
Physical Address,City,and Zip rL ft
-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 72.Certification:
32 q 2_' _ W Y1
6.Is(are)the wells) rmaneut or Temporary Signature of Certified Well Contractor Date P 2
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or Felix° with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 iVell Construction Standards and that a
If 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 reniarks 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.
i
drilled: SUBMITTAL INSTRUCTIONS I
9.Total well depth below land surface: L/Q (fL) 24a. For All Wells: Submit this for within 30 days of completion of well
Tor multiple wells list all depths if different(example-3 n 200'and 2@100) construction to the following:
10.Static water level below top of casing: ZO (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: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
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: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
T 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
f
i .