GW1-2021-02298_Well Construction - GW1_20210722

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
02 n l�, u y�� •���� I FROM TER:ZONEs ,
Well Contractor Name FROM TO DESCRII'r1IN
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�2 2 rt. ft.
NC Well Contractor Certification Number aSs,OUTER:CASING for'n" -a5e'd:welli OR'•LINER fa""Geiiblet:
fj� FROM TO DIAMETER THICKNESS MATERIAL
1'° CC:9-/'/ /3,2 �r �.y7_ 7/ fa t ft. S." in.
Company Name / 3 7� v`
f &TIT04WCASINGOR:Tl7BING:
2.Well Construction Permit#: Sol FROM - TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC County,State Variance.etc.) n• ft. In.
3.Well Use(check well use): fL ft. in,
Water Supply Well:
FROM TO DIAMETER SLOTSUE THICKNESS MATERIAL
Agricultural []Municipal/Public 0 R rG in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft 11L
Industrial/Commercial Oesidential Water Supply(shared) ;s�.
§18r,GROUT.,�4;.er."a
Irrigation FROM TO .'..MATER AL'• EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. L
Monitoring Recovery fG f0
Injection Well:
& n .
Aquifer Recharge 00roundwater Remediation
S9l9:SAND/GRAVEIiPACICifa
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test r3StormwaterDminage fL it
Experimental Technology OSubsidence Control ft. R
Geothermal(Closed Loop) [3Trat:er `F20.?DRIL•'I.IDIGLOG aitactiiadiH6un18hcefi�ir.""�..".,. '>�.�_�•��z:;>rn>�.:s-+;:�s=:�:�=r•:
Geothermal(Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color bud soWmclr ern
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+ tL
4.Date Well(s)Completed:,2"— .�f�--
2 ( Well D)# IQ fL
Sa.Well Location: fL e :3 fa
-Frta `a ft fL r e,
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Facilityp/OwierlName y g p FacilityID#(ifapplicable) fL fL
W if` AMA 4 t Z-31'7 3 ft. ft. --
Physical Address,City,and Zip ft. ft.
County Parcel Identification No.(PEN) r?rnreSSln3 ul
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
®uy3` l�Iy13J7 W d � f
o� � Z
6.Is(are)the weil(s) ermanent or Temporary
S' ure ofCc ti d well Contractor ! Date
� By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to on existing well: E)Yes or !YJ"o with ISA NC4C OIC.0100 or ISA NCAC 02C.020O WiAComttucrion S&wdan*and that a
Ifthis is a repair,fill out knosm well construction ttlformetion and explain the nature ofthe copy ofihis remrdhas beenprovided to the wil inmr.
repair under#21 remarks section or on the back ofthis 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 i GW 1 is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J d 40 (B-) 24a.'For All Wells: Submit this form within 30 days of completion of well
For multiple ivel/s Art all depths ffdf ferent(example-3(d)200'and 2@100) construction to the following:
10.Static water level below top of casing: V (ft) Division of Water Resources.Information Processing Unit,
Ifwater level Ls above easing tare"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ft�/ (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: ga-hanx construction to the following:
(ie.auger,rotary,cable,direct push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centei,Raleigh,NC 276994636
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13a.Yield(gpm) Method of test: �.1`�.''1't 24c.For Water SUDDIV&Infection Wells: h1 addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: r rC r Amount: Q d completion of-well construction to the`county health department of the county
where constructed i
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources ! Revised 2-22-2016