GW1-2021-02224_Well Construction - GW1_20210722

7777
71
Prmt.Form .
WELL'CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor InPkecef
atioon:
�o 14.'WATER ZONES,p, .", —
Well Contractor Name FROM TO DESCRIPTION
3 y�f� o1Ho aY 5 It a VM
6SS ' `90 rt a�prn
NC Well Contractor Certification Number 15.OUTER CASING:for molt}cased wells OR-LIlYER ff a'ticable `
We FROM TO DIA ETER THICKNESS MATERIAL
ft fL in.
Company Name 16-INNER CASING OR.TiTBING,(geotl J"er'inalclosel-1o0 ) -
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. fL in.
3.Well Use(check well use): ft. IL
Water Supply Well: FROM REE TO DIAMETER SLOT SIZE THICKNESS
-_ S MATERIAL
Agricultural unicipaUPublic 0 fL ft. fn,
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial DResidential Water Supply(shared) ; ,GROUT
Irrigation FROM TO MATERIAL { EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft• fL n 1 jh Q
Monitoring _Recovery fL ft `
Injection Well:
Aquifer Recharge QGroundwater Remediation ft. fL
Aquifer Storage and Recovery Salmi Barrier 119.',SAND/GRAYEL`PACB ff:a`livable':.
q g ry tY FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage rL ft '
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRIILING LOG'atfach'addi6onai sfieets if necess' 1.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(w1or,hardness,will it rein sirx,et,)
ft. ft. �� L
4.Date Well(s)Completed:S�I—2 Well ID# n. 3 O ft. !(�
5a.Well Location: ft. 05 ft
4/75 IJCu--loliV_ fL . rL
Facility/owner Name ,�j �/ I� /;/�FacifityID#(iifapplliic/able) H• H• w
Isay PIA - 'Ul' K C ��e(�/► (Vc .27(o� fL ft
Physical Address,City,and Zip ft. ft j t� 2071
,a
County Parcel Identification No.(PIN) it
ne$$Ing Un
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one la��t/llongg its sufficient)
22.Certification:
36a '7 - WJN Q J
S Z Z
6.Is(are)the well(s)!-' ermanent or Temporary tifrerM on ctor Date
D signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or No 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 due copy of this record has been provided to the well oimer.
repair under#21 remarks 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: I Q SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: V A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 rci n200'and 2@100') construction to the following:
10.Static water level below top of casing: o(� (ft.) Division of Water Resources;Information Processing Unit,
1f,ruler level is above casing,use"+" 161.7 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
/_v c` above,also submit one copy of this form'within;30 days of completion of well
12.Well construction method: 1W construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) V
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: / 1636 Mail Service Center' Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: la 24c.For Water Supply&Iniection 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: 117-H Amount: completion of well construction to the kcounty health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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