GW1-2021-02172_Well Construction - GW1_20210721

WELL CONSTRUCTION RECORD(GW 1) For Internal Use only:
1.Well Contractor Information:
Wen FR TER TO DF�IYON
3S 4 �N � � ft.
3-1 ft- � GPnL
NC Wen Contradar Certification Number �UL 2021 1�ISft- es-ft' (� (Pun
`(" �91 prC�£S5k(l�Uill iTiFRC-1NG formal was ORIDLUALM S a ca
Company Name l 1 1 P� ' �f�d� SL30O 1 i- �o b 14 � 0 0�10
` 1 1G MNER CAS OR TUBING thermal closed-loop)
2.Well Constriction Permit#: �(j "I FROM TO DIAMEmt IMCE74M MA123ML
List all applicable weU construction permits(as UIC.County.State.Variance.era) a- R. in.
3.Well Use(check wen use): 1L ft. ha
Water Supply Well: 17 SCREM
FROM TO DIA111ElER SLOT SIZE 1111Cffium MATERIAL
3AVicultural DMllnletpal/Publte U ft. ft. In.
Geoth-W(HeatiWCooliog Supply) Residential Water Supply(single) n n
Indmstrial/Commcrcial Residential Water Supply(shared) 1&GROUT
FROM TO MATERIAL EMPIACENMIT MEIHOD&AMOUNT
Non-Water Supply Wen-. Q 3rt.
Monitoring QRecovery 3 II' O ffi
I
well:
ft. tt
Recharge OGroundwater Remediation
19.SANDIGRAVE1.PACK da hleStorage and R—v-y �SallnityBarrier FROM TO MATERIAL E11 HAS MUROD
Test �Storarwater Drainage ft-
enfal Technology DSubsi&mceControl &mal(Closed Loop) Tracer 2&DRMU NG LOG attach additioml sheds ifnecesia .
mal(Heating/Cooling Retum) Other(explain under#21 Remad6) FROM TO -- DESCRW N oobr soar eel she,etc
ohs C7o I
4.Date Well as)Completed: aZQ Well IID# .32�9 0t S g fL -5 to fOl.01-N CM ,J I -10L
Slab.Well Location: it' ��R' �7✓ V-t'�(A,t,
hall o 0 0 lQ 4a r r I S tL fr.
Facnilily Name FaatiW IDS(if applicable) R'
6 Lq n ft. ft.
physical Addresr,Ci .and Zip It.
e, 118 ZL REMARKS
County Parcel Identi5eationNo.(P"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,are lat/long is sufficient) 22.Certification:
N ` 9 . 3A qla, W
6.h(are)the well(s)oPermanent or Temporary signature of Ocitified WeTC&ftactor Q Date
BY signing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this s repair to an existing well: Yes or ZINo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Weft Construction Standards and that a
Ifthis is a repair,fW7 out known weU construction i4iormation and a plain the nature ofthe copy ofthis record has been provided to the well owner.
repair under il21 remarks 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-I is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
dulled: _ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (fL) 24a.For All Wells: Submit this form within 30 days of completion of well
For muhiple wells list aU depths ifdff-wit(example-3@200 and 2@100) construction to the following:
10.Static water lewd below top of casing: (1L) Division of Water Resources,Information Processing Unit,
If water level is above caring use"" 1617 Man Service!Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Infection Wens: In addition to sending the farm to the address in 24a
/] 1 ®�� above,also submit one copy of this fort within 30 days of completion of well
12.Well construction method: l 7 !` '\ oonstruction to the following.
(Le.auger,rotary.cable,direct posh,etc-)
Division of Water Resources;Underground Intjection Control Program,
FOR WATER SUPPLYQWELLS ONLY: 1636 Man ServiceCenter,Raleigh,NC 27699-16M
13a.Yield(gpm) O 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
13b.Disinfection type: C�i Amormt: completion of well construction to`the county health department of the county
where constructed.
Form GW-1 North Carolina DWartmeut of Environmental Quality-Division of Water Resources Revised 2-22-2016