GW1-2021-02388_Well Construction - GW1_20210727

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WELL CONSTRUCTION'ik' E ORD GW-1 For Internal Use Only:
I.Well Contractor Information:
94i�4A'EMZ0NlfS
MFROMTO DESCRIPTION
Well Contractor Name . ,. ,tft.a�-�-� . ftNC Wcll ContraMor Certification Number ItCASRfer TO DIAMETER THICKNESS MATERIAL
ft in.
Company Name 1 lg; WCASIN
2.Well Construction Permit#: '
b 'L FROM TO DIAMETER THICKNESS MATERIAL
PP •� ry• t I ft ft ?� to Kj
List all applicable well construction permits r.Ul .County.State.Variance.etc.)
ft ft in.
3.Well Use(check well use):
Water Supply Well: F
i a7:SCREEN: ,
PP Y �;� FROM I TO I DIAMETER I SLOT SIZE I THICKNESS It MATERIAI.
Agricultural unicipal/Public ft ft. in.
!
Geothermal(Heating/Cooling Supply)' idential Water Supply(single) fc. ft. in
Industrial/Commercial esidential`Nate,Supply(shared) i8:GROUT. `
.Irrigation i I FROM I TO MATERIAL EMPLACEMENT METHOD
/&AMOUNT
Non-Water Supply Well: ',I ft. ft
Monitoring j ecovery ft. ft' Ad16A
Injection Well: ft, fr.
Aquifer Recharge i round-watcr Rcmediation
l9:SANWGRAVELPAIMflifaMicsible i;
Aquifer Storage and Recovery i alinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test `i tormwater Drainage ft fr'
Experimental Technology 1 [3 ubsidence Control ft. ft
26:'It1CIIZiING.I OG!'iiriadidiHts'Le7f
Geothermal(Closed Loop) ❑ racer "...
FROM TO DESCRIPTION(color.hardness.soiVroek type.grain Sim etc.)Geothermal(Heating/Coo ling Return);' n ther(explain under#21 Remarks) ft ft.
4.Date Well(s)Completed: 7 4L'ii Well ID# ft ft.
. �I ft
Sa.Well Location: ,
vr. L M6ay ;� f.t. fL
I; Facility ID# ifa applicable)
ft. fr
Facility/Owner Name ry (• PP• '
1 fL ft JUL IJ
• i�' .01
Ph cal Address,City,and Zip
p(OCeSBICI(�
/'j 1 � 'tl:sREhIARKS ' t G:
Coun;1 k 1 Parcel Identification No.(PIN)
County `
i
5b.Latitude and longitude in degrees/In[nut /seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3 ' �� ,
K,
6.Is(are)the well(s) Permanent oil I emporary Signature of Certified Well Contractor Date
1 By signing this form,I hereby certi�•that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: by or No with 15.4 NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out knoKrt well constructioA info ration and explain the nature of the copy of this record has been provided to the wek ner.
repair under#21 remarks section or out the back bf thi form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop G6oth mal 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. IndtCate OTAL NUMBER of wells
construction details. You may,also attach additional pages if necessary.
drilled: - SUBMITTAL INSTRUCTIONS
1
9.Total well depth below land surface:!! Z6 -(fit-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(exali�ple- 100'atul?@I001 construction to the following:
10.Static water level below top of eosin&; (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" i 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (i ) 24b.For Iniection Wells: In addition to§obdifig the form to the address in 24a
I;
L 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.)
1 Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:I 1636 Mail Service Center,Raleigh,NC 27699-1636
132.Yield(gpm)�i D ietho I of test: YY 24c.For Water SuoDly&Iniection Wells: In addition to sending the form to
the address(es) above, also Isubmit one copy of this form within 30 days of
13b.Disinfection type: A mount: I w completion of well construction to the county health department of the county
where constructed.
Form GW-1 Nth Carolina Department of Environmental Quality-Division of water Resources Revised 2-22-2016