GW1-2021-00373_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD(GW-1). For internal Use Only:
1.Well Cofntractor Information:
Well Contractor Name FROM
TO DESCPJMCK
Ll Q s.ft. &
NC Well Contractor Certification Number 'i.Itl(j ft. ( it.
L TO DIAbIETE$ MATERIAL f
��✓7 C.�// /� ry c ��i a1� , FROM TMC S
Company Name yft ) ''Z ft. In.
2.Well Construction Permit#:- '1'/ 7-.2 7 FROM TO D
List aU applicable well construction perrnits(i.e.UIC,County,State YarianM etc.) ft. ft In.
3.Well Use(check well use): & fb. In.
Water Supply Well: V w�i � .. z
FROM TO DIAMETER SLOT SIZE TffiCItNFsB MATFdtiAL
�MunicipaUPublic p R ft. In.
ermal(Heating/Cooling Supply) Residential Water Supply(single) R
Industrial/Cft. f86
ommercial E'Residential Water Supply(shared) . max 10
FROM 9O MATERIAL EIIIPIACFdNENTMETItOD� pUNT
on-Water.Supply Well: RO g t f
Monitoring Recovery
Infection Well:
ft
Aq
uifer Recharge R
arse' ®Gmundwater Remediation.
fer Storage and Recovery DSalinity Barriei FxoM TO uATErtt LR "='':s ,- �`$ '" '• _,:;
FMpLACEMFNT MSI9BOD
Test 0StormwaterDraitlage ft &
ental Technology3Subsidence Controlermal(Closed Loop) Tracerermal eatin Cooling Rgimn Other, lain under#21 Remarks FROM m D>tscteeTlod ceror e a ,eok '
4.Date Wells)Completed: Well»xi / ft.. ft.
raw
5aWell catlon:
FaoilityAn `�
J#(if applicable) ft goo o fL
y �-
rrS lr% .G ft. ft.
Physical Address,City,and Zip Z'�/9 S ft. - 1F •
Counb' Parcel identification No.(PIN)
LJL G AV IV it
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latilong is sufficient) 22.Certifications. � ra ��
- l—��r— I `�d t ( « 7z w W i;'tl'FG1ti /
6.Is(are)the wen ent orTemporary maercarrmeawenComractor ' Data
7.Is this s repair to an �,�- By�g 8 dd r form I hereby Cen*that the iveii(s)was(were)constructed in accordance existing wen: C)Yes or [3••a wt0r15ANCAC,01C.0100or15ANCRCO2C-02WWellComtrteamStgrtdmrirmadOata
IfOds is a repair,fill out known well construction information and explain the datum ojthe aP off.h' 1 has beeripmovided to the wall owmer
repair under#21 rmarks section or on the back ojthis form
23.Site diagram or additional well details: '
S.For Geoprobe/DPT or Closed-Loop Geothermal.Wells having the same . 'You may use the back of this page to provide additional well;s.W details'or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells c6nsftction details You may also attach additional pages if neceysery:..• '
drilled:
• SUBMITTA>_•INSTRUCTION '
9.Total well depth below land surface:
F-=di Z4s:For An Wells: submit this foim wifhin 30
1plewdkllMandep#w#'d/& mt(esample-3Q2W,and2@100). (L) days of coin' etiorh of'welt
constructiontotirefollowurg: .
10.Static water level below top of casing:_ R Division of Water Resources Information Process' Uni
/J•warer/evellfrabaveemYttg,><se"+" (R') , �, t, '
1617 Mtn Service Center,Raleigh,NC 276"..1617
11.Borehole diameter: (in.) 24b.For Infection Wells: Ia additio Ito sending the form t0 the-address in 24a
12.Well construction method: A"©' !'y above,also submit one copy Of this four within 30 days of odmpletion of well
(i e.auger,rotary,cable,direct lush,etc.) construction to the following
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27i99-1636
13a.Yield(gpm) __ Method of test: f r /V- 24c.For Water Sunnly&-Ialtg&g Wells; in addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
136.Disinfection type: Amount; �� 13 Z completion of wan construction to the county health department of the county
where constructed.
Form GW-1. North Carolina De
partment of Environmental Quality-Division of Water Resources
Revised'L'YLT1116