GW1-2022-10556_Well Construction - GW1_20221121

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
1
Well Comxactor Name FROM TO DES N
R R rJ /i
a. o ci S �
R R �
NC�+Well Contractor Certification
(Number
_ FROM TO D THICK[NIM MATE
`d fL —JA% ft- q- in- 1;bf_a-k
Company Name
2.Well Construction Permit#• la'0 — O ' FROM TO DIAMETER THICKNFM MATERIAL
List all applicable well construction permits(Le.I1IC,County,State.Variance,etc.) R R in.
3.Well Use(check well use): ft.
Water Supply Well: FROM TO DIAMETER SLOT SITE THICKNM MATERIAL
Agricult uai 0 unicipal/Public ft, ft, in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R It. in.
I ndustrial/Commercial DResidential Water Supply(shared))Irrigation FROM TO MATERIAL CEMENT TROD&AMOUNT
won-Water supply Well: O ft• ft• (A(`?��
Monitoring Recovery ft. ft.
Injection Well: S
R It.
Aquifei Recharge Groundwater Remediation
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13 Stormwater Drainage R it.
Experimental Technology 13Subsidence Control R ft.
Geothermal(Closed Loop) 13Tracer
Geothermal (Heating/Cooling Retum 00ther lain under#21 Remarks FROM TO DESCREMON color,hardness,saWroetr M vain ere.
R fL
4.Date Well(s)Completed: Well ID# tt S ft
Sa.Well Location: ft' ft. .— ;Q
R ft. �� _ ­
Facility/ Name Facility M#(if applicable) ft ft. N Q V 2
urw
Plz=AM74,City,and Zip ft. ft. "U, .: Ef t+`a'n-OG
`` c.
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:
N W 60rCIM/Y�.t�� 11—!is/lJ I � (h &'' d'.
6.Is(are)the wells) Permanent or OTemporary Signature of Certified Well Contrai 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 dNNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constnnction Standards and that a
If this is a repair,fill out burwn well cons wdon 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 fonn.
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 NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: S D (R) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@l M construction to the following: I
10.Static water level below top of casing: 3 (ft) Division of Water Resources,Information Processing Unit,
If water level is above Wig,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
Il.Borehole diameter: ( ) 24b.For Infection Wells: In addition to sending the form to the address in 24a
��.G� above,also submit one copy of this form within 30 days of completion of well
(Le Wei construction method: 111 construction to the following:
(i.e.auger,rotary,cable,detect Push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Iniection`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: 0 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016