GW1-2021-02355_Well Construction - GW1_20210723

WELL CONSTRUCTION IRE ORD CW-1 For Internal Use Only:
1.Well Contractor iInformation:
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Well Contractor Name FROM TO DESCRIPTION.
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JUL
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NC WellContractor Certification Number
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3tt4n ProcessIng Unii ?IIt OLfiEItSiG)►S1NG <1nOttf-t L�itietlf3-' Ri if
FROM TO DIAMETER THICK'QESS MATERIAL
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Company Name
16.E Q4FX'CASIN6:0R-[tiBt1�6' "
2.Well Construction Permit#: A 5✓ L G 3 FROM TO I DIAMETER I TRICKVFSS I MATERIAL
List all applicable wr1l construction permtts U1(.County,State. Variance,etc.) f4 {/0 7 ft. �' 7�y% in
3.Well Use(check well use): i ft ft- in.
in.
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERAAi.
Agricultural unicipal/Public ft ft. is
Geothermal(Heating/Cooling Supply I esidential Water Supply(single) fL ft.
Industrial/Commercial 1 j esidential Water Supply(shared)
II ';R.7G—
Irrigation '} FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: I i p fL Z3 ft- Al'eit i•— i
Monitoring ccovery fL ft. ,.
Injection Well: ' fr fr
Aquifer Recharge roundwater Remediation
14i'SAND/GRAVEI BACK if - irabli *
Aquifer Storage and Recovery i 13 alinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 3torrnwater Drainage fL ft
Experimental Technology i i Q ubsidence Control fL fL
� 1
Geothermal(Closed Loop) rracer ':?WDREUMgGWG littitcksddiiCo>hIiCH Ff'
Geothermal(Hearin Coalin Return) I ther(explain under#21 Remarks) FROM TO DESCRIPTION(color•hardness•sollfrock e• in sin etc.)~'
ft. ft.
4.Date Well(s)Completed: 7 Well ID# ft ft. • # Mob
Sa Weil Location:
f4 ft,
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C?-. 1,•err �,11 tt- t2
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Facility/Owner Name I Facility IDR(if applicable) fL it.ft 4614 f
a 1J o�h5vr.r �liYtn C,lq• t, .`Y
Physical Address,City.and Zip ft. ft.
CAILJ� I
r!# 1xIfEMtIRK$; ,>
Y _
County 0 0
l _ Parcel Identification No.(PIN)
Sb.Latitude and longitude in degree./.Y .ute lseconds or decimal degrees:
(if well field,one IaUlong is sufficient) 22.Certification:
f l if � 23-21
6.Is(are)the wells) ermanent or emporary a 77J • Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the%rills)was(were)constructed in accordance
7.Is this a repair to an existing well: bye i or �o %ith 15A NCAC 02C.0100 or 75.4 NCAC 02C.0200 Well Construction Standards and that a
lfthis is a repair,fill out knoxm well constructiol info union and explain the nature of the copy of this record has been provided to the well oxner.
repair under 921 remarks section or on the back bf M4 form. Ilk.
l 23.Site diagram or additional well details:
8.For GeoprobelDPT or Closed-Loop tht rmal 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. Ind i ate I OTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Z U (fG) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijlerent(example- @200'and 2@100� construction to the following:
10.Static water level below top of casing (ft.) Division of Water Resources,Information Processing Unit,
If water level is above rasing use 1617 Mail Service Center,Raleigh,NC 27699-1617
12.Borehole diameter: t/?/(/ !I (i ) 24b.For iniection Wells: In addition to sending g the form to the address in 24a
'!
12.Well construction method: V0. above,also submit one copy of this{form within P'days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) i construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:1 1636 Mail Service Center,Raleigh,NC 27699-1636
132 Yield(gpm) _rah LL l echimount:
of test: 24c.For Water Supply&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 type: t ry completion of well construction to the county health department of the county
"..
where constructed.
Form GW-1 !! Ndrth Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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