GW1-2021-00311_Well Construction - GW1_20211220

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Vell Contractor Information:
AL WATER ZONE
WxllContra"torName FROM TO DESCRIPTIIN
a ft .I fs 1 ft. �7
l�=L� - 4/6 ft. y ft.
NC Well Contractor Certification Number w1S,
OUTER CASING'04m6ltt eitised` R2INER a ble;
FROM ft. TOft. D� I'm. THICKNESSMATERIAL
Company Name T ` l/y2. :g.2
16s2?INNER`CASIl!tG.OR-TUBING` ttiermilelmed Ioo _..:a..x
2.Well Construction Permit#: / —3 ,7 W FROM TO DIAMETER THICKNESS A..I MATERIAL.
List all applicable well construction permits'(i.e.WC,County,State,Variance,etc) fL ft. i°
3.Well Use(check well use): ft. ft. In.
Water Supply Well:
FROM TO DIAMETER SWUSIZE THICIOMS MATERIAL
Agricultund [3Municipal/Public 0 a fL. in.
Geothermal(Heating/Cooling Supply) reential Water Supply(single) R ft in.
lndustrial/Commeroial E3Residential Water Supply(shared)
"Ilrrigation FROM To :MATERIAL EhRLAC NUM METHOD&AMOUNT
Non-Water Supply Well: 40 fL 3 S--& e n. 1 U O i
Monitoring ORecovery m ft. eu
Infection,Well: ,
ft fL
Aquifer Recharge [QGroundwater Remediation 19 SAND/GRAVELY Cic" fs llesb 2
Aquifer Storage and Recovery [3 Salinity Barrier FROM To MATERLAI, I EMPLACEMENT METHOD
Aquifer Test 03 Stormwater Drainage ft ft.
Experimental Technology E]Subsidence Control ft. &
Geothermal(Closed Loop) Tracer 720:DRiLLINGLOG ittir h idditionid'iibeets ifH
Geothermal(Iieating/Coolin Return .Other( lain ands#21 Remarks FROM TO DFBCRIPTION color sairhotk ere..
4.Date Well(s)Completed: 2 l Well ID# ft D ft a 4,, i d G t
5a.Well Location: 6 ft G
'p fL Jv-1. ft.
Facility/Owner N7/e J ^J7� / Facility ID#(if applicable) � fL ,,G ft. A f e 1 L]r n i •�
'�3: L cxi S./Sr;4J, 5,1E / �� le, ft' o�7j fL n /' w ✓J
Physical Address,City,and Zip V ft. fL
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) a a 22.Certification: DEC 2.0 2621 ,
07'�11v de' ,d �; �ltjr/ ' ir W f
s- I ,i, r•
6.]Kare)tire well(s)�rmanent or Temporary Si of ell Con
` Bi si ni NCAC 02C.01 er t car NCAC kthe well(s)was(were)constructed in accordance
-- - BY gmng_this_fonn,I hereby_certtfy that
7.Is this a repair to an existing weft []Yes; or BPle 62C.0200 WMI C i—tioucnan&Rnddr&i a-mat 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 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.
dulled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2 /.S� 00 24a.For All Wells: Submit this form within'30 days of completion of well
Far-11We wells Ustall depihs ffdoerent(Trample-3(a3200'and 2@1003 construction to the following:
10.Static water level below top of casing: (ft.) Division'of Water Resources;Information Processing Unit,
Ifwarer level Is above cmf ,use'•+ 1617 Mail Service Center,Roldg%NC 27699-1617
il:Borehole diameter: i ( (in.) 24b.For Infection 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:_ r A 115L'� construction to the following:
(Le.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) (o D Method of test 24c.For Water Suably&Infection 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:Wo f Amount y O 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 2-2242016