GW1-2021-00415_Well Construction - GW1_20211206

WELL CONSTRUCTION RECORD(GW-1) For Internal use y.
1.Well Contractor Information:
&Y-\n•l
.S'
Well Contractor Name FROM TO DES ON
as � 's - P. so ft. 3� , fL �; — 4
ft. ft.
NC Well Contractor Certification Number
hC FROM TO D rHll�[aVnF&4 MATERIAL
Company Name W U` d J \ ` O tt S. (o .4 in. ��CR.
2.Well Construction Permit#: aDa — aC1<J �—� FROM TO DUMETER TilzclavFss MATERIAL
List all applicable well consrucdon permits(Le UIC,Cowry,State.Variance.etc) ft. ft. in.
3.Well Use(check well use): ft ft in.
Water Supply Well: FROM TO DIAMETER SLOT 817E TMCE:NM MATERIAL
Agricultural LjM blic ft. ft.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft, ft, In
Industrial/Commercial Residential Water Supply(shared)
ifti 'on FROM TO MATERI" E METHOD&AMOi1NT
Non-Water Supply Well: Q ft &0 ft & ` t s SL3'
Monitoring Recovery ft. ft. ,
Injection well: °
Aquifer Recharge 13Cinoundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater aainage ft•
Experimental Technology DSubsidence Control ft. ft
Geothermal(Closed Loop) Tracer
Geothermal eatin Coo' Rettun Other lain under#21 Remarks FROM To DFseRlrlgox rotor b,rda soivrock ell
Q - L J ter-
4.Date Well(s)Completed: V I 0 Z Well ID# g ft• p!V
5a.Well Location: (� SO o ft C �� 4-
h o <-"C S051L
G f_
Facility/Owner Name Facility ID#(if applicable)' ft ft
4 W ►����C tL
Physical Address,City.sad Zip t-ic—X ft. iL
County Parcel Identification No. 4&g 1 u i!
if.r(1"rihlflilJl t ttvvt.�
5b.Latitude and longitude in degremhulnutes/seconds or decimal degrees.
(if well field,one lat/long is sufficient) t t 22.Certification:
360 ° � 15� q " N �° a`1 ` a, WCID d
R/M
6.Is(are)the well(s) Permanent or DTemporary Saguaros of Certified well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constricted in accordance
7.IS this a repair to an existing well: DYes or; No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fdl out known well construction information and esplain the nature of the copy of this record has been provided to the well owner.
repair raider#21 remarks section or on the back of thisform.
23.Site diagram or additional well details:
8.For GeoprobaMPT or Closed-Loop Geothermal webs 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.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: x lam) . 24a. For All Wellst Submit this'form within 30 days of completion of well
For multiple wells list aU depths if diiff-ent(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resource,Information Processing Unit,
lfwater level is above casing.use"+" 1617 Mail Service Center,.Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection 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
1L Well construction method: construction to the following:
(i e.auger,rotary,cable,direct push,etc.)
Divislon of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY//WELLS ONLY. 1636 Mail Service Center,Raleigh,NC 276994636
13s.Yield(gpm) 3 1� Method of test: 24c.For Water Supply&Inlection-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: ti (L`a Amount: O 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