GW1-2021-00428_Well Construction - GW1_20211206

WELL CONSTRUCTION RECORD(GW-1). For Internal Use Only:
1.Well Contractor I o do • /
/ a 14 WATERZONES
FROM DESCRIPTION
Wen Contractor Name
ft.
30 V. ft
NC Well Comactor "on Number S OUTER,CASING for.mah ram• . OR LllYER ri'.
/. FROM TO DIAMETER THICKNESS MATERIAL
C` ft a rS. in. / .
Company Name
a 16 13VN13ff t)Ii.T71B1NM
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
Lisi all applicabk well,co
permits Le.UIC,County,State.Variance,etc) N It. in.
3.Well Use(check well use): m ft in.
Water Sa Welt: 11:SCREEN .
PPb' FROM TO I DIAMETEPL I SLO'rSIZE I THICKNESS I MATERIAL
rl.dt
13Muni " blic0fcthermal(Heating/Cooling Supply) ideslttial Water Supply(single) ft ftmstrial/Commercial QReside ntial Water Supply(shared)Irrigation FROM TO I MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Welb f=
Monitoring Recovery ft. ft:
Injection Well:
ft. ft
Aquifer Recharge DGmundWatcr Remediation 1%.SAND/GR&VZL'PAEH
Aquifer Storage and Recovery 13Salinity Barrier gFROMo%TO MATERIAL. EMPLACEMENTMETHOD4
Aquifer Test' OStormwater DrainageExperimental Technology Mubside:nce ControlGeothermal(Closed Loop) TracerGeothermal eatin Cool ) Other( lain under#21 Remarks O DWCREPIION C=Iorl haftess.wiltrock Mr.pin sia,etc-)
io it ft ��
4.Date Well(s)Completed: Well ID# a Q f< y''p fL
5a.We Location: N
ft &
Famlity/Owner Name Facility D#(ifapplieable) % ft
Physical Add,City,and Zap & ft
2021
Lr' :21 REMARKS
County Parcel Identification No.(PIN)
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell fold,one Wong is suf5cimt) 22 Certification:
N W
6.Is(are)the well(s)014 a ent or [ Te Sigoauue of ed ell Contractor wic
By signing this form.I hereby cenfy.thar the well(s)was(were)eonsinicied Pit accordance
7.Is this a repair to an existing well: es Or E3No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifd&is a repair,flU ota known well construction it formation mrd esplaiu the natters of the copy of this record has been provided to the well owner.
repair under ar21 re narb section or on the back of thisform" 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.
hued: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /bl (fk) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dferenr(eranple�-3(a3(a�'00'and 2(a31003
construction to the following:
10.Static water level below top of casing: / (ft.) Division of Water Resources,Information Processing Unit,
1f ware'level is above cast&use"+ 1617 Mari Service Center,Raleigh,NC 27699-1617
11.Borehole etiameter, v (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
r 12.Well construction method / �, above,also submit one copy of this form within 30 days of completion of well
J D
(i.e.auger,rotary,cable,dicta push construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mani Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)_( Method of test: 24c.For Water Supply&Iniechon Wells: In addition to sending the form to
f the address(es) above; also submit one copy of this form within 30 days of
13h Disinfection type: f7'T Amount �G�� 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