GW1-2021-07466_Well Construction - GW1_20211116

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.W Contractor Information:
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Well contilGor Name FROM TO DFSCMIPTION
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NC Well Contractor Ce<t/ific�ationrNumber 15:Oi]TER(`ASING'[or.nNt1-cased.we➢s•�RLiAII+R da licetile y
Do by'S W t 1 l b(f M"le FROM TO DIAMETER THIC�VFM MATERIAL
Company ame } 1" ft. G f in. sox'Ll �L
,'i6�I1VNEit CASING_OR T[1BING° ot6e�al dosed�lbo :; ;..: =..`
2.Well Construction Permit#: 31 to D 35 FROM TO DIAMETER I THICKNESS IMATERIAL
List all applicable well construction permits(.e.VIC.County,&ate,Varranee,eta) � % in-
3.Well Use(check well use): ft fL in.
Water Supply Well: FROM To DIAMETER - SLM SM THICKNESS ' MATERAAI,
Agricultural DMunicipal/Public �,
-'Geothermal(14eatiog/Cooling Supply) nesidentiai Water Supply(single) ft,rLft. ft,ft in.
3.Industrial/CommercialResidential Water Supply(shared) ;18 GROUT - -
I lrri ation FROM I TO r MATEMIAI, EMPLACEMENT METHOD&AMODNT
Non-Water Supply Well: fL 790 ft. $ewEegi,��
Monitoring ,)Recovery tt ft r Pour
Injection wen:
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_ Aquifer Recharge E30roundwater Remediation
19:SAND/GRAVEI=PACKrfa '=-ee61e _ `_ _ _'- --
Aquifer Storage and Recovery E)Salinity Barrier
FROM TO MATERIALI EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control fL ft
_Geothermal(Closed Loop) Tracer 20.-DRMLIiING'WG:ittaciiadditlof al sheetsifnecessa
Geothermal Coolin Return Other lain under#21 Remarks FROM TO WSCRIPTIOx color hadn eoW k etc
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4.Date Well(s)Completed:I-ltr-,020 Well um 7-2 1L gs fL
5a.Well Location: SS fL
5kotl/l W001 $ rc /190 ft-
Facility/Owner Name Facility ID#(if applicable) fL &
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Physical Address,City,and Zip ft. ft.
A110A640nmr 3Dt �ZbFf zi:RtiMaxxs =< - r -
CountyJ Parcel Identification No."q DWR La111U
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
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6.Is(are)the wen(s)E31r1r1anent or OTemporary Signatqt&6f Certified well Contractor Date
� 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: Dyes or o with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,full out known well construction information and esplain 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 thisform. 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 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �f7 (fL) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tjdifferent(example-3©200'and 2©100� construction to the following:
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10.Static water level below top of casing: .25 00 Division of Water Resources Information Process' Unit,
Ijwater level is above awing,use"+"t 1617 Man Service Center,Raleigh,NC 27699-1 17
11.Borehole diameter. �y (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method-_ 4.,r go(Af 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:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) g.5 Method of test: A i r 24c.For Water Supobr&Lniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: 1 F _ Amount. 3 DZ completion of well construction tolthe county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016