GW1-2021-02300_Well Construction - GW1_20210722

i Rint,Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Co tractor Informatio4: . -
FROM TO DESCRIPTION
i"dell 'onuactor Name ? ft.
t fL
2 � J <
rt Sp fL 3 '
NC W I Co r7toertification/Nu er/tOl1TER CASING,foi indlli cased wells AR 1 INE13'-c i /n JCS / FROM TO DIAME R TIUCKKNESS MATERIAL
(((///��_ C�� r ft Z c9 fL r y to. �O t7
Company Name T
16ANNER CASING OR.T[n31NG( eotherinal Closed=too
.Well Construction Permit#: 4 o Y?-- 0 f FROM To DIAMETER ! THICKNESS MATERIAL
List all applicable well construction permits i.e.UIC,County,Slate,Variance,etc.) ft. ft. in.
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Z.Well Use(check well use): fL ft. in.
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i Water Supply Well: 17.iSCItECN
FROM Tn DIAMETER SLOT SIZE THICKNESS MATERIAL
;Agricultural QMunicipal/Public 0 ft- I. in. L `,-j q5
?IGeothennal(Heating/Cooling Supply) residential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared)
i Irrl alion FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. fL
,Monitoring DRecovery fL fL
In ection Well:
fL fL
OAquiferRecharge QGroundwaterRemediation ;19lSAND/GRAYELPAGK(if a hcable';:.
j�Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test []Stormwater Drainage ft fL
JExperimental Technology Subsidence Control tt. fL
FjGeothennal(Closed Loop) DTracer 20'rl)R[LLDVG,IsOG'.attachtndditionalslitieLsrfriecess ;
+.� - _ ness,s Ulmk rain Sim,etc.)IGeothennal(Heating/Cooling Return) '_ Other(explain under#21 Remarks rROM TO DESCRIPTION(color,hard
ft. 5 fL ,
1.Date Well(s)Completed: Well ID# tL fL 2" !.1
a""a.Mlell Location: fL fL .,
ft. rL
Facility/Owner Name. Facility ID#(if applicable) ft. ft. Vn►1
Of
1� tr/ i°lf�� _ ft. f4 t ��YCC;C" r
Plivsica A
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ress,Ci ,and Zip lj--- q f. ft
a K4' 17,g5G T/7�0t j
(J 21i REMARKS y
ouuty Parcel Identification No.(PIN)
3b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
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V.Is(are)the wells Permanent or DTemporary Signature of Certified Well Contactor Dat
/3y signing this fornt,1 hereby certify that the ivell(s)was(were)constructed in accordance
T.Is this a repair to an existing well: DYes orMS10 with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 lVell Construction Standards and that a
'f this is a repair,fill out!mama well construction infornuniort a d explain the nature of the copy of this record has been provided to the nlellpivner.
repair under#21 rentarks section or air 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: Q� SUBMITTAL INSTRUCTIONS
?.Total well depth below land surface: y (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
ror multiple wells list all depths if different(example-3 rr 00'and 2 ref 100') construction to the following:
10.Static water level below top of casing: 00 (ft.) Division of Water Resources,Information Processing Unit,
:;;,rarer level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
1i.Borehole diameter:�D (in.) 24b.For Infection Wells: In addition'to'sending the form to the address in 24a
12.Well construction method:
above,also submit one copy of this form within 30 days of completion of well
ff >�
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground'Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test: .Yl61 w 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: Amount: completion of well construction to the county health department of the county
where constructed.
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F-o ni GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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