GW1-2021-02354_Well Construction - GW1_20210722

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WELL COP STRUCTION!RE ORD GW-I For Internal Use Only:
1.Well Contract ir Information:
tl� •P. t a tit ! a'vArFaezA1v ...Y
WcllConuactorNa c Q../ FROM TO DESCRIPTIONp
a k. e x(�ft.
V ;
•L 2 2
NC Well Contractor Certification Number
ty
a r% L�iy tvo,n�'f�' FROM TO DIAMETER' THICKNESS MATERIAL
7v ft, ft. in.
Company Name [w y
�5 �,
2.Well Construe'on Permit#: .! FROM I TO DIAMETER I THICKNESS I`MATERIAL
List all applicable l construction permits Ul(,County,State, Parlance,etc) .t. t ft / 0 ft. 5,7/ in s
V
3.Well Use(chec well use): k. ft. i°•
Water Supply W ll: .'17.SCREEN
t FROM TO DIAMETER SLAT SEZE I THICKNESS MATERtAt.
Agricultural unicipal/Public in.
Geothermal(H ring Cooling Supply esidential Water Supply(single) ft. ft in.
lndusuiaUCo ial esidential Water Supply(shared) 18;GROUT
1lTI ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-WaterSuppl v Well: ;i ft j(
Monitoring j{ ecovery fL fa '
Injection Well:
Aquifer Recharg roundwater Remediation
Aquifer Storage d Recovery 19.SANDIGRAVM'PACK tf ble
Qry hnity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test Q ormwater Drainage fr ft.
Experimental Te hnology Q bsidence Control ft. it.
i
Geothermal(Clo ed Loop) I k cer :Zg;T_R_if_UN— •Lf :'at#a[chtiid isLr Isli! ~"'
FROM TO DESCRIPTION color.hardness,soil/rock e, in size,etc.)
Geothermal Hea ing/Cooling Return)j er(explain under#21 Remarks) ft. ft
4,Date Well(s)Co pleted: Well ID# ft. fl.
Sa.Well Location:
na r S S ft ft.
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
V ft ft,
Physical Address,City and Zip fLAl
fr.
County J I Parcel Identification No.(PIN)
5b.Latitude and III mgitude in degrees/ntinut econds or decimal degrees:
(if well field.one latllo g is sufficient) 22.Certification:
va-
6.is(are)the well(s Permanent oir mporary 3) Signature of Certified Well Contractor Date
i
By signing this form,1 hereby cert6 that the well(s)was(were)constructed in accordance
7.Is this a repair t an existing well: oVe i Or o r with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill at t known well constructicih info r tion and explain the nature of the copy of this record has heen provided to the well oxmer.
repair under k11 rema section or on the back bfthi rm.
23.Site diagram or additional well details:
8.For Geoprobe/D or Closed-Loop 66oth nal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 W-I is needed. Indicate TAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
4.Total well depth eiow land surface: `i �+ ZQ (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welts list a I depths if different(example- 200'and 2@1001 construction to the following:
10.Static water Iev4 I below top of casing-, (ft.} Division of Water Resources,Information Processing Unit,
ljwater level is above c tsing,use"+I./ ;i 1617 Mail Service Center,Raleigh,NC 27644-1617
11.Borehole diame r: 24b.For lniection 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 construetio method: r'V_ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUP LY WELLS ONLl!: 1636 Mail Service Center;Raleigh,NC 27699-1636
13a.Yield(gpm) MethD of test: ^ 24c.For Water Sunuly At Injection 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 ty ount: rt 1 completion of well construction to the county health department of the county
where constructed.
Form GW-1 N Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016