GW1-2021-02257_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only.
1.Well/C'�onttr�accttor IInnformatiio'n: 1y�
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FROM TO DESCRD'1ION
Well Contractor Name
o 5 00i, a Cdt r e
6aoft: a n. c ce ,
NC Well Contractor Certification Number
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C ' FROM To. DIAME THICKNESS MATERIAL
t 5D ft. fL (9 �ia 5�`(La.` C
Company Name
5S 13 (0 FROM
2.Well Constriction Permit#: N
nI ESS A•rFrrrer
List all applicable well construction permits(1.e.IIIC,County,State,Variance,etc.) ft TO ft DIAMETER in THICKNESS
3:Well Use(check well use): ft & is
1hrigation.
ater Supply Well: 1 m- - . :r �� ? •a s;,
FROM TO DIAMETER SLOT S12E THICKNESS MATERIAL
aml
Zr
Agricultural 13Munt blic fL It. In.
Geothermal(Heating/Coolmg Supply) esidential Water Supply(single) ft. % in•)
Industrial/Commercial Residential Water Supply(shared) -rt -, ,'�_., 1
FROM TO TF.RIAL E MENT METHOD&AMOUNT
Non-Water Supply Well: p ft. O ttC�o � 1 G-
Monitoring Recovery ft. ft. t �o
Injection Well: O ` M
ft. ft.
Aquifer Recharge Groundwater Remediation .. _..-. _.
ONaw—H—MI'll
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL LACEMENT METHOD
Aquifer Test [3 Stormwater Drainage %
Experimental Technology Subsidence Control ft. %
Geothermal(Closed Loop) 13Trd= r ih`d ...., .. ';tom r ; ,•
Geothermal (Heating/Cooling Return) Other lain under#21 Remarks FROM TO DE§G&TMON(eft,ha ness,soivrocktype,grain s' etc.
tt.
4.Date Well(s)Completed: Well 1D# ft S ft'
5a.Well Location: 0 tt• e "
Facility/Own7>ar'e Facility ID#(if 2PPMVAO
Physical Address,City,and Zip �C H• i
c l v
_CL
��15—a-. 3 �.
County Parcel Identification No..(PIN)
5b.Latitude and longitude in degrees/minutes/sewnds or decimal degrees:
(ifwell field,one lattlo/ng is sufficient) 22.Ce .VOL1011�fCCE'SSl(1l� Unit
14
N � ¢o .1 // W oVvIR" n
GiY► 6 1
6.Is(are)the well(s) rmanent or Temporary Signature of Certified well Cantrac r Date
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• 13Yes or o with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
1f 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:
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 1 GW-1 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: o (R-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: O C7 (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: (in. 24b.For Infection Wells: In addition to sending the form to the address in 24a
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 WELLC � Y: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ` Method of test: _ 24c.For Water SuoDly&Iniection Wells: In addition to sending the form to
`, . r rr the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: b 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