GW1-2022-08955_Well Construction - GW1_20220919

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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PROM I TO DESCRIPTION
Well Contractor Name 0 ft. ft. I
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NC Well Contractor Certification Number J5 i0U'1B12iCA$1NG'f1Tr,mtl sed3ve ' OltR'If=a.`11oAti t4 �
Ca 4t„,�� j '�V �a V FROM rt TO ft.
DIAMETER THICKNESS MATERIAL
Company Ame, 2 � I' IICA�1NGlQR:T B .. x"e tkerrn6l( u9edF 3 r.r „ _. `,_i
2.Well Construction Permit#: '`_tJ'L'0j 5 FROM I TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC(7ounty,State,Parlance,etc.) ft. ft. In.
3.Well Use(check well use): rt. tt. In.
Water Supply Well: FR°MD TO
xs �aDETER SLOTSIZE I THICKNESS I MATERIAL
Agricultural DMunicipal/Public ft. I ft. In.
Geothermal(Heating/Cooling Supply) ;Residential Water Supply(single) ft. ft. In.
Industrial/Commercial DResidential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. Q tt. (c
qnS
:)Monitoring [!Recovery
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19..StiV1)/ P�iCIC.Ifa Iiliable a s�S r_ z 3�,:r:
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology oSubsidence Control ft. tt.
Geothermal(Closed Loop) Tracer z 0MRIL11131INGi BOG:iittao`rad'UP bu"al�heets�t[tfe e a`;' ,. � :
FROM I TO DESCRIPTION color
Geothermal eatin Coolin Return Other(explain under#21 Remarks Eardoeav eolUrack rein a etc)
a 0 ft. 019 ft. ' ct L
4.Date Well(s)Completed: D y3�— Well ID# U ft. '!U'S ft. lJ Y at rl 1 '7 e-
ft.Well Location: tt. ft. ,�
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Pvs-& �Iawk ins
Facility/0 nerName Facility IDN(ifopplicable) ft. ft. SF P 1 'Q 202Z
I'96, 13zar C,-roI rt. ft.
ft. ft.
Physical Address,City,and Zip
,/1/I c 12o w>✓11 :�.:t.lzi'Il►laltTC5" �-� ti ;�,: � .z F��,��. _<.:;
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
(ifwell field,one lat/long is sufficient) 22.Certification:
5 .75gy3 N 81r9531y w
� Signature of Certified Will Contrectorj Date
6.Is(are)the well(s) Permanent or Temporary
By signing this,/orm..I hereby certify;that th'e tivell(s)was(were)constructed/it accordance
7.Is this a repair to an existing well: C)Yes or JMNo with 1SA NCAC 02C.0100 m•1JA NCAC 02Ct0200 Mell Constructl m Standards and that a
If this is a repair f ll out known well construction Information and explain the nature of the copy of this record has been provided to the well owner.
repair under#11 remarks section or on the back of this form. 23,Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop_&othermal Wells having the some You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
construction,only I GW-1 is needed.,Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: U 5 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths/fd/fferent(example-3Q200'and 2@1005 construction to the following:
10.Static water level below top of easing:e ID (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mall Servlce�Center,Raleigh,NC 27699-1617
11.Borehole diameter: Cf (in.) 241b.For Inietition Wells: In addition to sending the form to the address in 24a
f�
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: A O-�—nr Y 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 27699-1636
13a.Yield(gpm) _ Method of test: Ar 24c.For Water Sunnily&In)eWbn 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: I Yl Amount: C U' S completion of well construction to the county health department of the county
where constructed.
Revised 2.22-2016
Form GW-1
North Carolina Department of Environmental Quality-Division of Water Resources