GW1-2021-03299_Well Construction - GW1_20210603

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
i
ROt M F t
FROM I TO I DESCRIPTIO\
Well Contractor Name ft
tl,r 6 IL ft
NC Well Contractor Certification Number ;M OUTER;CASING'for.=ulh
, � FROM TO DIAMETER THICKNESS MATERIAL
C.arava Servtct 4t CeK ruc�bn -t I ft 'Af I 54A `{0 PVC
Company Name :
2,Well construction Permit#: J l✓✓ `5- tom' A l 1 `5" FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i e.UIC.County.State.Variance.etc.)
R ft
3.Well Use(check well use): IL It in. -_
_.
Water Supply Well: FROM TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public 0rL 3'Lb ( t/ in- i o, Sch qv I U�-
Geothermal(HeatingtCooling Supply) residential Water Supply(single) ft. ft in.
Industrial/Commercial Residential Water Supply(shared)
Irrigation FROM tTO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Weil: f7 IL 2- n- 3 p {CNr ✓rd
Monitoring ©Recovery ft ft
Injection Well: ft ft
Aquifer Recharge Groundwater Remediation
19::3iYNillGRAY�IP-k8 3 t
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3StormwaterDrainage Z� fL 32. � f�2 ua� DuI G
Experimental Technology Subsidence Control It. ft.
Geothermal(Closed Loop) Tracer 2t3 I)RILI.ING7AG attt a6iids r = »
FROM TO DESCRIPTION(mtor.Iurduar,soilho k ti etc
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft ft 4l✓ 0lA R
4.Date Well(s)Completed:. Well ID# fL 2 2 t
Sa.Well Location: Z Z 3 2 R W
r� �Y�h lgr'ewK It ft
P.
'- Facility/Owner Name Facility IDS fL ft,(if applicable)
l(.OZ 5,114dfrd0tler Rd . Caralla ZQ IN ft ft.
Physical Address.City,and Zip ft ft 3 2
lo(/QaosDollouv! �1 ;
.farrl4 kck
e,s3Jng
County Parcel identification No.(PIN) ^^ "� Pfr,dG
-
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if svell eO Zv
ld one llat;on� 3y t is sut N fficient) O f f/ 22.Certification;
33 . - 15' 5b Z9 w
6.Is(are)the well(s) Permanent or Temporary SigtartrredKertilRd well ntractor Date
l3v signing this form.I hereby rertifi-that the svell(s)ivas(were)constructed in accordance
7.Is this a repair to an existing well: EYes or J3No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consrrurtion Standards and that a
If this is a repair,fill out known well ronsiruriinn information and explain the nature of the ropy of this record has been provided to the well osvner.
repair Larder#21 remarks section or on the hack 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 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: 2 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 (ft.) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@ 00'and 2@100') construction to the following:
10.Static water level below'top of casing: (ft.) Division of Water Resources,-Infotmation Processing Unit,
If water level is above rasing,ase" 1617 Mail Service Center,Raleigh,NC 27699-1617
t
11.Borehole diameter. (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one cope of this form within 30 days of completion of well
12.Well construction method. �w4 e� construction to the following: i
(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
13a.Yield(gpm) V Method of test: (sky �u� 24c•For Water SuDDiv&I Iiection 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: �l 1 �- Amount: (r S O Z completion of well construction'to the'county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of water Resources Revised 2-22-2016