GW1-2021-07625_Well Construction - GW1_20210903

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: �"T
1.Well Contractor Information:
14.-WATER'_ZONES ;r
Well Contractor Name FROM TO I DESCRIPTION
t't, tit.
NC Well Contractor Certification Number 15.OUTER CASING'tbi 7olultl csseii welts;OR LIVER It a Icable `
FROM TO I DIAMETER TMCIOVE53 MATERIAL
Company Name ✓1 C ' ft 7()ft. 6 ia. S I
16.INNER-CASING OR TUBING(geotbaT"dosed.loonl-
2.Well Construction Permit#: �( D3(/0 2 c? - 2,020 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i e.UIC,County,State,Variance,etc.) ft. ft• yin
3.Well Use(check well use): R• R• in.
Water Supply Well: '17::SCREEN
AgriCulturel FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�M nicipai/Pubiic 0 ft• ft• in.
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) e• ft• ➢n.
Industrial/Commercial i_;Residential Water Supply(shared)
18.`.GROUT.,: t
rri ion FROM TO MATERIAL EMPLACEMENT METHOD do AMOUNT
Non-Water Supply Well: 0ft ft. �/ n' p DD
.Monitoring D Recovery ft. ft.
Injection Well: Ott
ft. Ew
Aquifer Recharge E3Groundwater Remediation
.19.SAND/GRAVF.L;PACg(itapblable ,- -
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additionatsheets if necessary):-
FROM TO DESCRIPTION color hardn soiVlock size,ete.
_ Geothermal Heatin Coolin Rettun �Other(explain under#21 Remarks O � �
4.Date Well(s)Completed: Well ID# R• n•
Sa.Well Location: R' R'
/�
a/Oyi rC,
Faciliity/Owner Name
p (I Q I Facilirf HID#(if applicable)
/� R R-
�1�2- L Jg-+V/,,so&l CAUL l�F.�LICL. t jl
Physical Address,City,and Zip _ R R• Q vn\
21 REMARKS.
County H'aicel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one latAong is sufficient) 22• roll
3��2� �ZL/ N — 79. '7��Z �¢W .
3OZ 7� /2 Z/
6.Is(are)the well(s) rmanent or OTemporary SigmArc of 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: 13 Yes or MK- with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well 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 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells Construction details. You may also attach additional pages if necessary.
drilled: SLn3AI I'AL ENSTEM-M-ONS
9.Total well depth below land surface: 3 99 O (ft•) 24a•For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2®100') construction to the following:
10.Static water level below top of casing: (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. (0 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
�D `N 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) c' Method of test: 44c.For Water Suunly&Injection Wells: In addition to sending the form to
1. the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: r�n..c•► ec'S completion of well construction!to the county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016