GW1-2021-00391_Well Construction - GW1_20211230

0
WELL CONSTRUCTION RED 1RD(GW-1) For internal Use C._
1.Well Contractor Information:
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
1z LW W rt. ft.
NC Well Contractor Certification Number 15.OUTFRCASING far nvlH casediwe7ls UR:F INER fa lic�lste s
rljrq//�j,- FROM '1'O
Company 111.4 MIE 1'KR 'I'H ICBKNY;SS M.4'rY:H1A1.
,Name GN © f,I. _re ft. / in.
t4.
t6.1NNER;CASIINCOIL•F1iB11V� Spthorimal-o)oscd loo =
2.Well Construction Permit#: DDO 1, FROM TO D1.4METER THICKNESS I MATERIAL
List all applicable nrll construction permits ff e.UIC,Counrn,State. Variance,ere.) ft.
3.Well Use(check well use):
I
Water Supply Well: 17:SC32E)N !
FRONT TO DIAMETER CLOT SIZE TH►CICII-ESS MATERr4L
Agricultural Municipal/Public ft; ft• in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(Single) ft. ft. in,
industrial/Commercial OResidential Water Supply(shared)
..GROUT_,
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&ANIOUMI'
Non-Water Supply Well: o ft.P
Monitoring ORecovery ft-
ft. �� E
Injection Well:
ft ft
Aquifer Recharge Groundwater Remediation
19.SAIND/GRAVEL PACIf<If a'iii i61e)
Aquifer Storage and Recovery EJSalinity Barrier FROM TO MATERIAL EMPI.ACENIENTMETROD
Aquifer Test E)Stonnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DIULLING OG attach additioi al sheets it eeessa ._' s ,
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION wlor,hardness,sof Crock type.gmfn size,eta
Dft. L f ft.
4.Date Well(s)Completed: 7-4S--Z/ Well iD# ft. ft.
Sa.Well Location:
rt. 6p rt. 51,a Af
Facility/Owner Facility 1D#(ifapplicable)
.zit TPtLK/'sg �S'du/1Gl1 guy /l��/j>/Y �CfM6 ft. -
Physical Address,City,and Zip ft. ft. nn LL�' 3 0 2
'l r
C�1ev d,Ee e zhix>MAxts [ur�am,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifivell field,one lat/long is sufficient) 22.Certification:
35" 0S . 3r N 66Y, 03- .ZIZ N
6.Is(are)the well(s) 'ermanent or OTemporary Signature of Certified Well Contractor Date
By.signing this 1or•nr,I hereby certifj•that the svell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [)Yes or No with 15.4 NC'AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
//'this is a repair.fill out k norm well construction injonnation and explain the nature ofthe copy ojthis record hay been provided to the it-ell owner.
repair under#21 remarks section or on the buck ofthis.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 ito 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0J—
00 24a. For All Wells: Subnut this!form within 30 days of completion of well
For multiple wells list all depths ifdijjerem(example-3(&,,200'and 2(a,:/DO') construction to the following:
10.Static water level below top of casing: T e (ft.) Division of Water Resources,information Processing Unit,
!(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: r 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) �Z Method of test:�°Y 24c.For Water Supply&Iniection Wells: In addition to sending the form to
� �: the address(es) above, also submit,one copy of this fnmi within 30 days of
13b.Disinfection type: L Amount: ;`f C u' completion of well construction to;the county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources { Revised 2-22-2016