GW1-2021-07909_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Tontractor Information-
V"
414.;VATER-ZONES -,�!.,�
Well Contractor Name a FROM TO DESCRIPTION
ft-
��iS4 ft. 21
Q-7 9/ —A ft. 2 V-41 ft. C, Sol—
NC Well Contractor Certification Number
for-multi UUTER CASING wells�01t LITTER'if
FROM m TO I DIAMETER— I THICKNESS MATERIAL
OnAv -,"s we-[I �V' in. Sal,-Al I A--e—
,�- t —3 1 -Compfiny Namd 16'.-WNETVCASING`OR :-,-
2.Well Construction Permit#: FROM TO DIAMETER. CKNESS MATERIAL
List all applicable well construction PeTnUIS�(I.a .[C,County,State,Variance,etc.) ft. ft.
n.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.'SCRJEEN'`
ft
Agricultural 13Municipal/Pubfic; PROM fL TO . IAMETER SLOT SIZETHICKNESS MATERIAL
s.
in.
:—)Geothermal(Heating/Cooling Supply) 0<esideritial Water Supply(single) R. fL in.,
:)Industrial/Commercial OResidential Water Supply(shared)
711rrigation FROM TO A MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: "- - 26, IL
DMonitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge []Groundwater Remediation 190 SAND/GRAVEL-PXCK-(ifapjilic-a I ble)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METFFOD
Aquifer Test OStormwater Drainage
Experimental Technology DSubsidence Control
+f1: ft.
Geothermal(Closed Loop) OTracer a20.1-D - I LOG(affach'additioniii sheets if.nbcessiry)
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) I FROM TO DESCREMON(color,hardness,soilfrock type� in size,etc.
Iweuuw )
�4.Date Well(s)Completed:4-1�f c? It kzy�- ft- ge-ez-
ac ft. 3 od f". A",Otk ve-
5a.Well Location: ft. ft.
A lteLaSeal i
,e, ft. ft.
Facility/Owner Name Facility fl:)#(ifapplicable) ft. ft.
ft. ft.
Physical Address,City,and Zip ft. ft.
'21.-PSWARKS
OAL
County k, Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well ficld,one lat/long is sufficient) 22.Certiffeation-
N W J&MV-J,& A/-
6.Is(are)the well(s)Qfermanent or OTemporary Signature of Certified We 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: OYes or ONO 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[lie copy of this record has been provided to the well owner.
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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: - '—(ft-) 24a. For All Wells: Submit this' form within 30 days of completion of well
For multiple wells list all depths lidifferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top Of casing: 4 (ft.) Division of Water Resou'rees,Information Processing Unit,
If water level is above casing.use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For InjectionWells: In addition to sending the form to the address in 24a
12.Well construction method: 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) Method of test: 24e.For Water Supply&Inlect ion Wells: In addition to sending the form to
the address(es) above, also subniit one copy of this form within 30 days of
I
13b.Disinfection type: H I-A Amount: 7 &Z, 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 Revised 2-22-2016