GW1-2022-07251_Well Construction - GW1_20220805

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Info
V FROM TO DESCRIPTION
Well Contractor Name ft. ft.
NC Well C tr for Certification NuAcr 0
FROM I TO DIAMETER THICKNESS MATERIAL
Nwnsl LitIN-Paill, I ft. 1)5'ln. �,Dp -7
Company Name IF 164- 'r I". , _)
'Fit
wrc. egft ft&"Ifiox -4 )0
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. In.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)
In
3.Well Use(check well use): ft.
FW. WTIF
ter Supply Well: FROM TO DIAMETER SLOTSIzE I THICKNESSss I MATERIAL
Agricultural [3MunicipaMblic ft. ft. in.
Geothermal(Heating/Cooling Supply) V-sidential Water Supply(single) ft. ft. In.
Industrial/Commercial [3Residential Water Supply(shared)
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: — -6) ft. Z) It. pbu-red 114 h d-a5
7-il Monitoring' [3Recovery ft. ft. V
Injection Well: ft. ft.
3Aquifer Recharge E]Groundwater Remediation N.
A"4'USM4
1 Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
3Aquifer Test 13Stormwater Drainage n. ft.
:)Experimental Technology 13 Subsidence Control ft. ft.
:')Geothermal(Closed Loop) OTracer MIM
n!-Geothermal(HeatingtCooling Return) :Other(explain under#21 Remarks) FROM I TO DESCRIPTION(color,hiardness.sollfrock type�arain six ei etc.)
n ft
4.Date Well(s)Completed: oil ID# ft.
ft.
5a.Well Location:
D 6-Y6 A99 9
Facility/Owner Name Facility IDN(if" Ii able)
Mot)�e Irctupriation Prcc&,r.,�.ng Unft
ft.
Physical Address ity,and
Z'F
0'kn rk
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certiflcadon;
35; 37Z6 6 N Cal�1
6.Is(are)the well(s)eIrmanent or [3Temporary Signature of Certified W611 Contract qV Date
By signing this form.I hereby centry that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)ves or JNiqo with 15A JVCAC 02C.0100 or 15A NCAC'02C.0200 Well Construction Standards arid dear-a—
If this Is a repairfill out kilown well construction Infonnallon 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
ER ofwells construction details. You may also attach additional pages if.necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMB
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface (ft-) 24a. For All Wells: Submit I this form within 30 days of completion of well
For multiple wells list all depths 6(doerent(example-3@200'and 2@ 100) construction to the following: i
10.Static water level below top of casing: 3o (ft.) Division of Water Resources,Information Processing Unit,Ifivater level is above casing,use I '
617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: KO (in.) 24b.For Iniection Wells: lit'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
construction tc
12.Well construction method:. Y-0 ry )the following:
(i.e.auger,rotary,cable,direct push,etc.) I Division of Water Resources Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Servlc'e Center,Raleigh,NC 27699-1636
In addition to sending the form to
13a.Yield(gpin) Method of test: 24c.For Water Sony In form within 30 days of
the address(es) above, also s6bffiit one copy of this
At: completion of well construction'to the county health department of the county
13b.Disinfection type: Amount: where constructed. I �
I Revised 2-22-2016
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources