GW1-2021-06942_Well Construction - GW1_20210505

`Print Form.
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
-1.Well Contractor Information:
'0*1(-Q)( \ 14.WATER ZONES
Well Contractor Name FROM
JJam�)) ft. TO DESCRIPTION^t O ft. 0�
.9aOf, a✓[7�ft. ItoLJ
NC Well Contractor Certification Number 15.OUTER CASING(for multi cased wells OR LINER if a licable
�l n I f�C • FROM TO DIAMETER THICKNESS MATERIAL
Jl 11 f, ft. in.
Company Name 16.`iNNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: e1 d,ZC� - oo a 3 ( FROM TO DIAMETER THICKNESS MATERIAL
Livi all applicable well con.sb,uctioth permil.v-(i.e.(11C,('ounty,5'late.Variance,etc) O ft_ 1 t 9 ft. /� 2S' in. SAR 21 171 ri
3.Well Use(check well use): ft. ft. tY J in.
Y V�
Water Supply Well: 17.SCREEN `
pp y FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural []Mumcl Public ft ft. in.
Geothermal(Heating/Cooling Supply) Idennal Water Supply(single) ft. ft. in,
Industrial/Commercial L l Residential Water Supply(shared) IS.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. ft- e ��C O u-
Monitoring []Recovery ft. ft. r, t
Injection Well: t
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery ;Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test nStormwater Drainage
Experimental Technology n Subsidence Control
Geothermal(Closed Loop) nTracer 20.DRILLING LOG(attach additional'sheets ifnece'ssa "-
Geothermal(Heating/Cooling Return) ;Other(explain under#21 Remarks) FROM TO (DESCRIPTION(color,hardness,soil/rock type, rain size,etc.
ft. 11al ft. ` U I OVe r
4.Date Well(s)Completed: �7 Z� Well ID# 1 ff OT-ft YQYI t
5a.Well Location:
M cif,< 11 f- To n-es ft• ft.
Facility/Owner Name Facility 1D#(ifapplicable) ft. ft.
ft. ft. pry ? ru
46( _TOV,es LQQ 1�RivC ' , JG a8l3D k`+
Physical Address,City.and Zip T ft. ft.
R'W'C'l11 b-, 4/J/. 000 21.REMARKS
County Parcel YIdentification 7No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: it i"�t4Cr1 pr Qessirlg U51
(ifwell field,one latftn7 is sufficient) 22.Certification: I D� 5Ww
t' 1 93�51 N FfL° a2 ' 5S. og5 011L w
6.Is(are)the well(s) ermanent or Temporary gnature of Certified ell Contractor Date
t3v sfgninR this.fihrnh,1 hereby certify that the weA(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or udih 15A NCAC 02C.0100 or 15A NCAC 02C 0200 Well Construction Standards and that a
If this is a repair,fill out known well contraction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 421 remarks.section or on the back of 1hir 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
construction,only i 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: '? (ft.) 24a• For All Wells: Submit this form within 30 days of completion of well
For multiple we/tv list all depths rfdrflereni(exanhple-3@200'anl2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing unit,
Ifwaierlevel is ahure casing,use"-t"� 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: • 2J (in.) 24b. For infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of thisffonn within 30 days of completion of well
12.Well construction method: V_�!24 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
11 i
13a.Yield(gpm) 1 Method of test. 6 I• nflf&'n QK 24c. For Water Supply& infection 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:C iO,.ru Amount: +011S completion of well construction to the county health department of the county
where constructed. i
i
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources V Revised 2-22-2016