GW1-2022-03654_Well Construction - GW1_20220321

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well
-Contractor Information:
.
`J G�MI SON CA 14:WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
W13 - Pv 0 It. 320 1 11 DL,>
NC Well Contractor Certification Number 32o ft. 3qo I D�
Y� '15I'OUTER"CASiNO'for jdMtl eSea�ivV `OR 3iII�FR'(tr a le)�v
\J l ln�DS 1 I hC FROM ft. TO ft DIAMETER in. TffiCKNFSS MATERIAL
Company Name
P Y n 16.HiNER.C-ASING'IOWTUB]NofkeothernW closcR=luij ) g n 5 a
2.Well Construction Permit#: oC 1)©y 1 2 O Ll S FROM TO DIAMETER T FUCKNFSS MATERIAL
list all applicable well construction permits(ie.U1C.County.State.Variance.etc.) (' ft. c ft• in. Six Z p I/C
3.Well Use(check well use):
Water Supply Well: FROM EEN !;(
FROM TO DIAMETER S[ATS� THICIINESS MATERIAL
Agricultural [Muni blic ft ft. in:
Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft, g, in.
Industrial/Commercial Residential Water Supply hated
pp y(shared) I&GROUT
ation FROM TO MATERIAL EMPLACEMF2 f METHOD&AMOUNT
Non-Water Supply Well: Q ft' p ft' t It rou
Monitoring DRecovery
Injection Well: `
Aquifer Recharge 13Groundwater Remediation
19 AND/GRAVM AGRrtf;""livable -.s �3.s ,.< f'r ir;
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMI LACEMENT METHOD
Aquifer Test C)Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) 1ITracer 20.DREUJNGLOG.(ntte&additional sheets If
FROM TO DESCRIPTION mbr bards sofUroct osize de.
Geothermal(Heatingcling Return) Other(explain under#21 Remarks
O ft S ft' C,a 6,vty6LkrcW k
4.Date Well(s)Completed: - --a 9- Well LD# 1 S It. ly ft-
Sa.Well Location: ft' ft'
41 kc C)e—l- ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft' ft -•.3 ,";' +'`i
c2lLl-1 -Terr•l S �Gp I-I•PMomemoVe i f-C 2779 2 ft. it
Physical Address,City,end Zip ft' ft.
t 6 911 d 7 5 Z 1 21`REMARKS' :.
sv
County Parcel Identification No.(PIN)
V,A !\IYli'l 1'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Certification:
S3 ° 2—W 7, 32-IuoZN 'q2-0 2 3' 51,2`1Sg 15 W
6.1s(are)the well(s)eWermanent or Oi Temporary S' tore of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 01res or with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on 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 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: (R•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifili ferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (D 0 (ft.) Division of Water Resources,Information Processing Unit,
if„inter Level is above casing,use
r"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. Ul r (in.) 24b.For Injection Welts: 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 oonstradioa method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,'Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1&%
11 � l
13a.Yield(gpm) Method of test: TA t't1f 24c.For Water Supply&Inj_action Welts: In addition to sending the form to
lL-- the addresses) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: fnh ldr',+� Amount: fo,ki S completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resourcell's Revised 2-22-2016