GW1-2022-09611_Well Construction - GW1_20221021

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: 1
v-,
gArrd� "-----------
FROM TO I DESCRIPTION
Well Contractor Name J ft. rt.
454-5—A — ft. ' ft,
NC Well ontractor Corlifloation Number 41
FROM TO I DIAMETER THICKNESS MATERIAL
�LM4 ( ,. 5 In. DR't I P VC,
Company Name I ...................
2.Well Construction Permit#: 6 0 FROM TO DIAMETER I THICKNESS MATERIAL it
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc,) ft, ft. In.
3.Well Use(check well use).
Water Supply Well: FROM I TO DIAMETER SLOTSIZE THICKNESS MATERIAL
.JAgricultural [3Municipal/Public ft. I ft. In.
:]Geothermal(Heating/Cooling Supply) [Wesidential Water Supply(single)
:]Industrial/Commercial DResidential Water Supply(shared) ............
'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6) tt. 2_0 tt. K 'DourtA. 14 bm6
:)Mcmitoring E3Rccovrry
Injection Well:
3Aquifer Recharge [3Groundwater Remediation
ADAM
Aquifer Storage and Recovery [3Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) [3Traccr
Geothermal(Heating/Cooling Return) r3Other(explain under#21 Remarks) FROM ft. TO I DESCRIPTION(color,hardness,sollfrack bye,grain sim etc.)
10 0,
ft
4.Date Well(s)Completed: --Well IDO 4aV fecyk l'te-,
5s.Well Location: tt. Frt- J mo;
ft. N E:D
J6- tA—r mo,i�_ A) e- C E
2
Facility/OwnerN7 Facility ID#(ifapplicablo) ft. tL
�:no y1d__JVy1 a_
Physical Address,City,and Zip LIM
County Parcel Identification No.(PIN)_
5b,Latitude and longitude In degreeshninutes/seconds or decimal degrees.
(if well field,one lat/long is sufficient) 22.Certification,
a 3 N fA— ��� 1 /D— i i—,�2—
6.Is(are)the well(s)ePermanent' or 13Temporary Signature of Certified Wall Contractor V Date
By signing this forin,I hereby certify that the well(s)was(were)constructed In accordance
7.Is this a repair to an existing well: []Yes or JoNo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis Is a repair, out known Nell construction IrIformallon and explain the nalta'a 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 TOTAL NUMBER of wells Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I OW-1 is needed. Ind
construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below lan&surface: 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths Udocrent(example-39200'and 20100) construction to the following:
10.Static water level below top of casing; (ft.) 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: lIn addition to sending the form to the address in 24a
t above,also submit one copy of this form within 30 days of completion of well
Y-o
12.Well construction method: ax4 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
13s.Yield(gpm) Method of test: .24c.For Water Suggly&Ilniectlon Wells: In addition to sending the form to
ii� the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
13b.Disinfecdon type: Cklill'IA!L Amount: where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016