GW1-2021-03406_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
IV 14:-S4 ATER,ZANES
Well Contractor N e FROM TO DESCRIPTION
JL'N X ? 2021 34o fL 3�F3 ft. C(e-o"f
NC Weli Contractor Certification Number t ♦ tf Unit t5:tjUTFR CASING for lti cases Pi)
ells)VRL7NER:iEa licable
AAUG'' JnfGrM-360I1 " r.,,, IR� FROM I'O nI�h1 N,rER 1'HIIC�KNNESS MA('TERIAL
]19 r �d�U N 9,1 DWR SQ�tlon -- - �+� 11. It. i m• S V 1��I 1'V
Company Name
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'.16.�hINER CA$INt;OR TUBING Cothermul�etoscd•Ieo' ' ;
2.Well Construction Permit#' 09 1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Count'.State.Variance,etc..) ft. ft. in.
3.Well Use(check well use): ft. R. in.
t?.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public
Geothermal(Heating/Cooling Supply) 6Residential Water Supply(single) ft. fL in.
industrial/Commercial Residential Water Supply(shared) -
Irrigation FROM I'O MATFIRIAI. EI17Pr,ACFMF.NT hIF:rHOD&AaIOUN•r
Non-Water Supply Well: O tt- ft. r 1u Q
Pump
Monitoring ORecovery IL
p ft.
Injection Well:
ft. ft.
Aquifer Recharge []Groundwater Remediation .
19:SAND/GRA; PXCX6f R 'ticfible} ....:;
Aquifer Storage and Recovery OSaliniry Barrier FROM TO MATERIAL EMPUICEMENT METHOD
Aquifer Test []Stonnwater Drainage ft ft.
Experimental Technology []Subsidence Control ft. fr.
Geothermal(Closed Loop) []Tracer 1[L DIULIA.G?L(1G attach additfonhl sheets it stecessa :�
Geothermal(Heating/Cooling Return) EJOther(explain under#21 Remarks) FROM fL o�- ft. A.
TO DESCRIPTION color,hardness,soil/rock e, in size,etc.
4.Date Well(s)Completed: S-(J-9 1 Well iD# LA rt. ft.
ft.
Sa.Well Location: ? ft. C
n1n Torni n(f0y I C11 ft. ft.
F��aci^^lity^^/ rner-N�am^e� ,,Q Faci�litylD#!(if applicable)
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OCI JCJ W tJIXJt Q�r/t L��L Tl7AA 1�Q� '1 Z ft. ft.
Physical Address,City,and Zip ft. ft.
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification'
350 N ���3° `f3- go'-I- W
6.Is(are)the well(s)iermanent or OTemporary Signature of Offified Well Contractor Date
� °1 By signing this Joro,l herehy certij'that the weil(s)was(were)constructed in accordance
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7.Is this a repair to an existing well: Yes or No with 15.4 NCAC 02C.0/01)or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair.fill out known well construction injonnation and explain the nature of the colty of this record has been provided to the well owner.
repair under 921 remarks section or on the back of this_(trm.
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: 3LOO -(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample-3(a�200'andGG2(d,/00') construction to the following:
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10.Static water level below top of casing: (ft.) Division of Water Resources,information Processing Unit,
1(water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: m. I
( ) 24b. For Infection Wells: in addition to'sending the form to the address in 24a
/1 2 above, also submit one cup),of this form'within 30 days of completion of well
12.Well construction method: F-Fl construction to the tollowing: 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) • Method of test: ,A't✓- 24c.For Water Supply&Injection Wells: In addition to sending the form to
I / the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount' ! completion of Well construction to,the county health department of the county
where constructed.
Fomi G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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