GW1-2022-01670_Well Construction - GW1_20220128

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WELL CONSTRUCTION RECORD(GW-1). For Internal Use Only:
1.Well Contractor Mn-
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G 14 WATER
Well Contactor Name FROM TO DESCREEIITON
,t &
NC Well Comraaor Ce11 fieav umber I&VUTER:CASING for . . OR IZiER.d
FROM TO I DIAMETER THICLtNLSS M ATERIAL
ft fL in
Company Name
1616I1 :G1i51tiTGOR.TIJBIriG:
2.Well Construction Permit#: [/ b FROM TO DIAMETER I TMC 04ESS MATERIAL
List all applicable all construction permits(le.UIC,County,State.Variance,eta) fL & in.
3.Well Use(check well use): ft in.
i.N
ter SupplyWell: 3 N
FROM TO DIAMETER SLOT SUE THICKNESS MATERIAL
gricultural crpal/Public 0 R R in
eothermal(Heating/Cooling Supply) Residential Water Supply(single) 8 m
ndustrial/CommercW QResidential Water Supply(shared)
hod on FROM I TO MATERIAL MVEMLTHOD&AKOUNT
lGeoth.mal
o Water Supply Well: fL (' ftonitoring Recovery ft ftection Weil: ftfc
quifer Recharge [3Groundwater Remediation 19..SAND/GRAVEL' EBquifer Storage and RecoverySalinity Barrier FROM TO MATERIAL EMPLACEMENT METHODquifer Test' DStormwater Drainagexperimental Technologym Subsidence Con rol ft ft.
eotheral(Closed Loop) ®Tracer eatin Cool' ) Other( lain under#21 Remarks) FROM TO DESCRRTo cobr,hnrdMM=iVr=ksW%etc
ft R
4.Date Well(s)Completed: Well ID# 60 fL
52.W il Locaypn: b
Facility/Owner Name b4-' Facility ID#.(ifapplicable) ft fL ( �
e Gr„ ha G
i 0h sical City,and Tap ft ft
J/p 1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ld400g is sufficient) 22.Certification:
N W at
6.Is(are)the wells) Permanent or 13Temporary TWaWm of Certified Well Contractor
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: �or E3No with 15A NCAC 01C.0100 or 15A NC AC 02C.0100 Well Consouctmn Smndards and that a
If this is a repair,Jill out brown well aatastructton rnfonmatiavr and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 rrvnzab section or on the back of this 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 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: 00 24a. For All Wells: Submit this form within 30 days of completion of well
For mnittpk well;list all depths#'diferent(esmnple-3@200'and 2(a31003 construction to the following:
10.Static water level below top of casing: (fL) Division of Water Resources,Information Processing Unit,
if water level is above casm&use/+ - 1617 Mail Service;Center,Raleigh,NC 27699-1617
11.Borehole diame (in.) 24b.For Injection Wells: In adIdition.to sending the form to the address in 24a
12 Well construction method: 0 �� above,also submit one copy of}his form within 30 days of completion of well
(i.e.auger,rotary.cable,dues push,eoc)
construction to the following:
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service lCenter,Raleigh,NC 27699-1636
132.Yield(gpm) Method of test 24c.For Water Supply&Injection Wells: in addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13h Disinfection type: ? V Amount O 7 completion of well construction,to the county health department of the county
where constnucied.
Form GW-1 North CarolinaDepartment of Environmental Quality-Division of Waxer Resources Revised 2-22-2016