GW1-2022-06053_Well Construction - GW1_20220629

WELL CONSTRUCTION RECORD(GW-1) For Internal Use only:
1.Well Contractor Informatio :
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Well Contractor Name FROM TO DFSCRIPYTON
ft. ft.
NC Well Contractor Certification Number
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Co an Name `C� ` ft. 6. 26m l �In• �Q�r��
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5
2.Well Construction Permit#: l� � T FROM O DIAMETER I THICHNI S MATERIAL
List all applicable well constriction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. Ia
WIN
ter Supply Well: �;.,�:s•,.,.` .,-•.
FROM TO DIAMETER SLOT SEES THICKNESS MATERIAL
gricultural crpal/Public ft. ft. to
eothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. � In.
ndustrial/Commercial [3Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
n-Water Supply Well: _ p ft. o`Z o ft. rxc! e S o 16 , r
Monitoring Recovery ft. ft. M,` 'z w Injection Well:
ft. ft.
quifer Recharge Groundwater Remediation g quifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
quifer Test 13Stormwater Drainage % f
xperimental Technology Subsidence Control � fL
eothermal(ClosedLoop) Tracer _eothermal(Heatin Coolin Return) Other lain under#21 Remarks FROM TO DESCRIPTION color,burin saWrock etc
ft.
4.Date Well(s)Completed.-A a al� Well ID# `�0 p %SO
5 ell Location: 0 ft. ft. _ P'j
Facility/Owner Name Facility ID#(if applicable) ft. ft.
b\ e e•.�,,A�'-�ar,� : �� \� 5.0f� v.c . ��- f ft. Ptad k_�'���Phys' 1 Address,City. Ztintl ip
O P b 5- \al �n
County Parcel Identification No.(PII�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(' d, g ) / / 22.Ce tion:
rfwellfiel one laUlon is sufficient / t x�'-' •'r�• �:'� •+ I ); Y
L/\/ ki��'�l.�hD11fLr"�I'�YS�JL+r.Lya!! i
5 0 -n I ASS it N Q a,d \ p �, 3 W cv�iL�-m 3 a AzQ.
_ 6.Is(are)the well(s) Permanent or TempoWNo
a Signature of Certified well Contras r Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or with ISA NCAC 01C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out brown well construction information and explain the nature ofthe 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 1 GW-1 is needed Indicate TOTAL NUMB 'wells construction details. You may also attach additional pages if necessary.
dried: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: g 00 24a. For AD Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdlfferent(example-3Q200'and 2 a 00) construction to the following:
10.Static water level below top of casing: UP Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
n O 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: ` 24c.For Water SuuDly&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: (� Amount: 16 o-Z 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 Resources Revised 2-22-2016