GW1-2021-07464_Well Construction - GW1_20211006

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: -
/Ic�o n t
Well Contractor Name r� OM TO DESCRIPTION I
3 14cl l-A ft. ft
� �t;�eo� a 5 ft.
ayv
NC Well Contractor Certification Number
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,.T-FROM OIYCEKRSIIttG. ahtniitttFaSedwells OR:TINEIt 1Ea `drkhle
Q To DIAMETER THICKNESS MATERIAL
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Company Name -I- 3 6 [t in. r ecci
O /^O ti ';3'd.'1NNER'CASING;ORt1 USING' efithersiial dastilaUa3
2.Well Construction Permit#: L C l o FROM I TO I DIAMETER 11 THICKNESS MATERLV
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL fL in.
3.Well Use(check well use): ft fL in.;
i
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public 0 ft. ft
Geothermal(Heating/Cooling Supply) Pkesidential Water Supply(single) n tt in.
Industrial/Commercial Residential Water Supply(shared) 18tGROtIF:;.
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O H. O ft 0
Monitoring ORecovery ft. It.
Injection We1L ft. ft
Aquifer Recharge Groundwater Remediation
491. AND/GRAYEL';PAGK ita"Iicabl6
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIALL EMPLACEMENT METHOD
Aquifer Test [DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control R. H.
Geothermal(Closed Loop) OTracer A20i;bRihTillYG 1 OG':.iiitach':iiiiditionalsheetsiitnecess
Geothenmal(Heating/Cooling Return _;Other(explain under#21 Remarks FROM TO DESCRIPTION(mlor,hardn solVmk f. ralu sift,ete
rt ft O� ! L
4.Date Well(s)Completed: -/ '( Well ID# Gr
5a.Well Location:
ft ft `
/rlfrcha�L Sfrb+ham ft. ft
Facility/Owner Name Facility IDN(if applicable) 0- 0-
1-J S Q .Ri%VC r c h (A);16oe, 14Jc a� 9�— tt. fL
Physical Address,City,and Zip fL IL
VU I �S�n ei31lREMARHS_ �-.,`:
Comity Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,onQne�l-at/long is sufficient) 22.Certification:
:3SJ l7 �M N ^37,Q�t(a3 W
6.Is(are)the well(s) Permanent or OTemporary Signature of C,�d Well Contractor Date
By signing this form,I hereby certify that thewell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or ONO with 15A NCAC 02C.0100 or 15A NCAC 02C'.0200 SVell 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 ivell owner.
repair raider#21 renmrks 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.
drilled:- i SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: c10s (n-) 24a. For All Wells: Submit this form within 30 days of completion of well
For mulliple ivells list all depths if different(example-3 a200'and 2@100) construction to the following:
10.Static water level below top of rasing: to (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: b (in.)
246.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
r Y above,also submit one copy of this form within 30 days of completion of well(i.e.auger, construction to the followin rotary,cable,direct push,etc.) g'
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ``'' 1636 Mail Service Center;Raleigh,NC 27699-1636
13a.Yield(gpm) I�C7 Method of test: J/V 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: A J li Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016
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