GW1-2021-02229_Well Construction - GW1_20210722

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WELL CONSTRUCTION RECORD(GW.1) For Internal Use Only:
1.Weil Contractor Inf mation:
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Well Contractor Name FROM TO DESCRIFrION
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NC Well Contractor Certification Number /J ;15e OUTEIi'CA91NO fui mtdtd146ietl ivelis';O1LLilYE11'V a 'II£k file
JJ�/�� Jily£� L�' �mI/ FROM TO DIA R , THICKNESS MATERIAL ,.
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Company Name
::16PIN1HER GA51NG.,OR'.T'UIt1NG:: eotliermal'closed-loa } ,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) R h in.
3.Well Use(check well use): ft ft in.
Water Supply Well: - FROM I TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural <.icipaVPublic 0 ft rt in
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) tI tt, in.
Industrial/Commercial DResidential Water Supply(shared) ;.1k GROUT';',
Irrigation FROM f TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fit. fit ) t z' �
Monitoring EIRecovery It. M
Injection Well:
ft. fit
Aquifer Recharge OGroundwater Remediation
19::S' /GRAY L`'PAi K it,0011cablb
Aquifer Storage and Recovery OSalinity Battier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage n- It.
Experimental Technology Subsidence Control ft. rt.
i Geothermal(Closed Loop) OTracer IOAM 1 LIXG LOGO ettaeh additi6pal
�. Geothermal Heating/Cooling Return) Other(explain under 921 Remarks) no za DEscatPTloN tutor na,a,+ess solt/r«k rain size,etc.)
f. ft.
L71
?•.DateWell{s)Completed:Sa��"Z( Well fL 3Q ft. jLc
Sa.Well Location: rt `pit ft +
Facility/Owner Name Facility ID#{if applicable) H- ft
( CaA*rr"hurty 1�C{ w/e(�h //c .2ye fit
WS
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Physical Address,City,and Zip IL fit
T\ /►T 31.RE1vIARRS. nI.
County Parcel Identification No.(PIN) Ott - '"Oil
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well
"field,one)lap�tljlongg is suusufficient) f� Q ) 22.Certification:
CPgS l N --79. � OL
f,Is(are)the wells) rmanent or OTemporary t on actor Date
D signing this form,1 hereby cerlify that the';well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or ON. 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 bark of this form.
23.Site diagram or additional well details:
S.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 I GW-I 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: 0 U� 00 24a. For All Wells: Submit this form'within 30 days of completion of well
for multiple wells list all depths if different(example-3Q200'and 2@100') construction to the following:
10.Static water level below top of casing: rd (ft.) Division of Water Resources,Information Processing Unit,
t f water level is above casing,use"/+" 1617 Mail Service Center,'iRaleigb,NC 27699-1617
11.Borehole diameter: rb (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
j7� �,I�cf above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: IL / 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
(13a.Yield(gpm) / Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the Form to
t the address(es) above, also submit one 1copy of this form within 30 days of
!13b.Disinfection type: Amount: 4 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
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