GW1-2022-01672_Well Construction - GW1_20220128

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information: �
—+aM%S011 G t 6 SQ t,/ \ 14 WATER:ZONES
Well Contractor Name FROM TO DESCRIPTION
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ft. 0#0"• N61100
ft• Zf ". follow
NC Well Contractor Certification Number
n y� a"IWOtTTEWCAMDHG- _ iiHl�ce�e0
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wp Se Y'V�C�S / I r\C FROM I TO DIAMETER Twin LASS MATERIAL
R. ft. in.
Company Name 16:INb4R:.CASING 0R'TUBING`.`eothEiro iloae"-too ) _,.f�sa aMfr, 1'-<
2.Well Construction Permit#: CO1 CC>1 I ,5_R Z. FROM TO DIAMETER MBCRNESS MATERIAL
List all applicable well construction permits(ie.UIC.County.State.Variance.etc.) Q R. ' a S ft. Z s in. 8 S' .g
3.Well Use(check well use): ft. "' in.
Water Supply Well:
FROM TO DIAMETER SLOT S17E THICKNESS I MATERIAL
Agricultural [3Municipal/Public ft. ft, I in.
Geothermal(Heating/Cooling Supply) DRes: tial Water Supply(single) ft.csr
Industrial/Commercial dential Water Supply(shared) 18 O
Irrigation FROM TO MATERIAL EMPIAC nC&Vr METHOD&AMOUNT
Non ter Supply Well: 6 ft e�0 ft. Let11 I-e ow
Monitoring Recovery ft. ft. ,
Injection Well:
ft. fL
Aquifer Recharge 13Groundwater Remediation
�`.19ti AND1CRAYMT V CK cfri
Aquifer Storage and Recovery OSalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology ®ISubsidence Control
Geothermal(Closed Loop) 13Tracer 20 DRILLING LOGi(att5cli edditl6hal slicetiiaf
Geothermal(Heating/Cooling Return) Other(explain under 421 Remarks) FROM TO DESCRIPTION color,haWaM solltmt tM,grain slzr etc.
R. OVCr C4✓0U Yl
4.Date Well(s)Completed: 1-3 - 1 Well ID# 1 Zr ft. 70S-"'
Sa.Well Location: ft. ft.
M.C. ye nhkyc S t (n C. ft. ft.
Facility/Owner Name Facility ID#(if applicable) R. R.
d a Makv 1 l'e I Cis Or. NendeYsmy, Ite,Nc ft' ft'
Physical Address,dity,and Zip Z 81cr L ft ft
Ne hdl'LyS0y% Q 5 88(D't 1 Z5(o Zr.RFdVIARiSs77
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lavlong is sufficient) 22.Certification:
650 18 g�,5114) N 8Z'> 2q ' 0.217 24 9' w �--- � �' 3' .21
6.Is(are)the wells) rtnanent -or. Temporary acute of Certified WeU Contraaar Date
BY signing this form,I hereby certify that the well(s)was(were)constmered in accordance
7.Is this a repair to an existing well: DYes or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
B.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 l GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL U49MUCTIONS
9.Total well depth below land surface: 5 _(ft.) ua. For All Wells: Submit this form within 30 days of completion of well
For muNple wells fist all depths if dderent(example-3Qa 200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: C.• 2 (in) 24b.For Injection Wells: In addition to sending the form to the address in 24a
�O I-G�Y�( above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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
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13a.Yield(gpm) Method of test: t illZ t 17 K 24c.For Water Suonty&Injection Wells: In addition to sending the form to
Q�S the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:0A%� �"' Amount: 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