GW1-2021-02149_Well Construction - GW1_20210505

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Onty:
1.Well Contractor Information:
The y� I 15ti
FROM TO DESCRIPVON
Well Contractor Name
ft. ft.
NC Well Cortbactor Certification Number 15�U1 ER EASING fo�amtilH eased
� 4I O O TO D TRICKKM MATEBIAL
CampanyName s /9g U4�
�3 161INNER-CA81DiGrUReTI1B v DIAINGMETE-rR. , .-
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2.Well Construction Permit#: FROM TO TMCKNEss MATEM'
List all applicable well construction permits(i e.WC,County,State,Variance,etc.) ft. fL In
3.Well Use(check well use): fL ft fir.
Water Supply WeIl: FROM s I DIANNIER
`sf oT s>� rmclavFss MATERIAL
❑Agricultural ❑Municipal/Public tt. 6t in.
❑Geothermal(Heating/Cooling Supply) Ellre—sidential Water Supply(single) ft. & is
Olndustrial/Commercial ❑Residential Water Supply(shared)
❑lrri ation ❑Wells>100,000 GPD FROM To MATERIAL Fnmi AcEnm" oD&AMOUNT
Non-Water Supply Well: 0 ft• a 6 ft (P 0 u T c-
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACENDUfr METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft,
❑(ieothermal(Closed Loop) ❑Tracer 20.,DR1lLLJNG;UA)G1 attiW4ddttionilsltlEta7
❑Geothermal(Heating/Cooling Return ❑Other(explain under#21 Remarks FROM TO DFscRipTloN Odor Intdn wivroclr etc
ft
0
4.Date Well(s)Completed: �r Well ID# ft a t: a
5a.Well�'O on: ft �-d & Sa
,Jr�(0`� Lo� 4 �� S--d ft. 30 ft• ran,
Facility/Owner Name Facility ID#(if applicable) ft. ft. *,•1� l.+
(903 S chi V S fL ft.
Physical Address,City,and Zip ft. ft
Fro f�
L
County Parcel Identification No.(PEN) e e ( e r\ ;t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(long is sufficient)
22.Certification:
N W /
- D-
6.h(are)the well(s): ermaneat or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cerdfy that the wil(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the 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 Wells having the same You may use the back of this page;to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells ( 'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 G (fL)
For multiple wells list all depths ifdifferent(example-3@200'and 2@100 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: V ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfwuter level is above casing,use"+;' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (�D (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
IL Well construction method: P10 40 r`
(i e.auger,rotary,cable,direct push etc.)-�/ 24c-For Water Supply and Open-Loop Geothermal Return Wells Copy to the
county envtronmenta ea th department of the county where installed
FOR WATER SUPPLY WELLS ONLY: ) 24d.For Water Wells roducm over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 91 Method of best: (i31 a L / Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 1 Amount: /b
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2019