GW1-2021-00314_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We Contractor Information: l/
r l �(lu, �7 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
NC Well Contractor Certification Number 15.OUTER CASING'for inultl-casedwells)OR LINER if a licable
FROM TO DIAMETER TffiCKNESS MATERIAL
i-` ft. a\ ft. '� in. I S( PYL
Company Name
16,INNER CASING OR TUBING eothcrmal closed-lob
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FROM REEN O DIAMETER SLOT SIZE THICKNESS MATERIAL
_!Agricultural [3Municipal/Public ft. a�tt. ✓A in. t a 40 P�L
_.
:)Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT.
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. ft. e^W,n, 311z b S
Monitoring 13 Recovery fit. ft.
Injection Well:
fit. fit.
Aquifer Recharge n1 Groundwater Remediation -
19.SAND/GRAVEL PACK if applicable
Aquifer Storage and Recovery []]Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStonnwater Drainage
Experimental Technology E]ISubsidence Control
_ Geothermal(Closed Loop) FnITracer 20'.DRILLING LOG(attach additional sheets if neccssa
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
J Geothermal(Heating/Cooling Return) rill (explain under#21 Remarks) O ft. ( ft.
to
4.Date Well(s)Completed 66 Well 1D# ft. ok
ft.
11)
Sa.Well Location: fit. \ ft' Q
K�rm O� A's ft. ft. l�av
Facility
Q/O
wner
1NaAmee \ ` ^ Facility Dunn
(if applicable) ft.
O v W cOA-5 I l l .1Junn �L - — fit. fit.
Physical Address,City,and Zip �/ j�(� ft.
Nara Q- �� b✓ - )ORD �� V 21.REMARK lam'`
S�
County Parcel Identification No.(PIN) l �P -3oZ 2 O
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
rf well field,one lat/lon is sufficient '
(' g ) 22.Certification:
l)
^CC 1� t
- ICJ N �S �C W + G�or/�/t,,,11t Ai-az)
6.Is(are)the well(s)oPermanent or OTemporary Signature ofC ified Well Con ctor Date o�
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: EIYes or No 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 in forma
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 fibrin.
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-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: 30( (fit.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiereni(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: (fit.) 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: (in.) 24b.For Iniection 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: muA 'Q0 construction to the following:
(i.e.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) Method of test: 1�1�1 11 2 (-1 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: Amount: f/ "I 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