_Well Construction - GW1_20230310 (62)

(Print Form
,ALL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1,
1. ell Contractor Information:
14.4.MATER.ZONES DESCRwT10N
Well Contractor Namfl ft. TO ft.
96Ks—,A •
NFoe
ll Contractor Certification Number 1$;OYITER CASING.tor•in d(tnsed ivblfs OR LINER'if a llcable
t s ill aK j �U t, FROM TO Z�k�Gth.
TRICEUMS TERLiL
W ft. 5 ft. i`Company Anne 6.• 13: ASINGQRutel'c'o5ed-too
2.Well Construction Permit#: FROM To DIAMETER TffiCKNESS MATERLU.
List all applicable well construction permits(i.e.WC,Cann%State,Variance,etc.)
ft. ft.
ft. ft. �•
3.Well Use(check well use):
17.SD EN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
. .Agricultural E)Muaicipalftblic ft. ft.
Geothermal(Heating/Cooling Supply) E3Rg1tiential Water Supply(single) g, ft. in
Industrial/Commercial E)Residential Water Supply(shared) Is.-GR UT.
Ilil atlnn FROM TO nn EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: V N.
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge ®Groundwater Remediation 19,SAhfAIGItAVEL FACIE f:a Iica le
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ��•, oStormwater Drainage
" ,fit.; ft. ft.
Experimental Technology I Subsidence Control
Geothermal(Closed Loop) OTracer 20.:DRILLIN LOG.attaeL' etc CRIPTIONcolor hardness sol#reckalze d tibn"Ieheet:if necessary)
ES
Geothermal Heating/Cooling Return) Other ex lain under#21 Remarks FROM TO D-3 " -
4.Date Well(s)Completed: y .; Well ED# 0 U5 ft. tit 1
ft. ft.
Sa.Well Location:
ft. ft.
Facility/Owner Name Facility ID#(if applicable) -a ,•-v' _.,_,
kAA-
953.3 Shn-r-+Pj- fi.e.w I �.r^1^dt 1✓ - ft.
PFrys;cal Ad city,and Zip IWAR
_
�7j � zt.RE MKS
County
Parcel Identification No.(PiN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees: '
(ffwell field,one lat/long is sufficient) 22,Certification:
3517737� N w
Si
6.1s(are)thewell(s)JOPermanent or [3Temporary
a of Certified Contractor
well Dat
By signing this form,1 hereby cert�that the wells)was(were)constructed In accordance
7.Is this a repair to an existing well: ®Yes or E)No with I SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,Jill out known well construction information and explain the nature of the copy ojthis record has been provided to the sveB owner.
-repair under#21 remarks section or on the back ojthis form. 23.Site diagram or additional well details:
robe/DPT or Closed-Lono;Geoth'crmel Wells having the same You may use the back of this page to provide additional well site details or well
8.For Geo
P. P construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: /) SiIBMITTAI.INSTRUCPIONS
9.Total well depth below land surface-9"" (ft-) 24a: For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths Ifd{,perent(example-3@200"and 2Q1001 construction to the following:
10.Static water level below top of casing; I d D (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 diatndter: (ins) 24b.For Injection Wells: in 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
12.Well construction method: AL �_— construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Infection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Ak 24c.For Water Suppiv&Injection Wells: In addition to sending the form to
II the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 101'Y✓�t— Amount: (,Ups completion of well construction to the county health department of the county
where constructed.
Farm OW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016