GW1-2021-03539_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD(GW-1) For Intemai Use Only:
1.Well Contractor Informatioon:
f'� T X-)14 o-A ✓ co b S 141 WATERZONES
FROM TO DESCREMON.
Well Contractor Name
- ft
`/)^ &R ft �
NC Well Contractor
Certification Number IS.-OUTER CASING for moltr used wells OR3IIIVE1t,tf f"' bk c' s
FROM To e 1 I o DIAMETER MUCENESS .MATER AL
It. ft. is
Company liAne
23 ., 2a s i&INNER CASING:OR TUBING( �-
2.Well Construction Permit#:V ' `� FROM TO I DIAMETER THICKNESS MATF3tIAL
Liss all applicable well construction permits(i.e.U1C,Coun)4 State,Variance,etc.) ft. It in.
3.Well Use(check well use): It ft in.
Water Supply Well: 17.SCREEN �...«n..
FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
Agricultural [3Municipal/Public 0 ft ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft
In dustriWCommercial Residential Water Supply(shared) 18.GROUT-
Irri ation FROM TO MATERIAL EMPLACKM]M METHOD&AMOUNT
Non-Water Supply Well: ft ft.
Monitoring pRecovety ft ft.
Injection Well: ft ft
Aquifer Recharge Groundwater Remediation
19.`SAND/GRAVEL'PACg rf a' "'b7e
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL. EMPLpCEMl'avr METHOD +
Aquifer Test [3Stormwater Drainage & ft
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer .20.DRILLING LOG attach additioniil btieets if:necess r :_
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DFSCREMON color,h:udnes%solureck type,gmin.lu,etc.)
D ' S-pS�ft (rr�4
4.Date Well(s)Completed: t� Well ID# ft ft
Sa.Well Location:
ft. ft �'
1 b,r'4 6 terc e- ft. ft. 7 2021
Facility/Owner Name Facility ID#(if applicable) & ft Us It
L4 I os �4 S. 1 C Q• n 1t Irfiorr�^.a ,i i I -
or
Physical Address,City,and Zip ft. ft LJ
a � 2L REMARKS._`.:.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W S.L f
6.Is(are)the weil(s)[Permanent or Temporary Signature of Certified Wet Conuactor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Ves or [3No with 15A NCAC 01C.0100 or 15A NCAC OiC.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 921 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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24s. For All Wells: Submit.this form within 30 days of completion of well
For multiple wells list all depths if eli erent(example-3@ 200'and 2@100') construction to the f0110W1I1
g:10. ,
f
ft Static water level below top of casing:
(ft) Division of Water Resources,Information Processing Unit,
/fwater level is above casing,use +" 1617 Mail Service Center,Raleigh,NC 276"-1617
11.Borehole diameter: `� (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: P,944p { above,also submit one copy of this'form within 30 days of completion of well
Y
(i.. construction to the followine.auger,rotary,cable,direct push,etc.) g'
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: / 1636 Mail Service Center,Raleigh,NC 276"-1636
13a.Yield(gpm) Method of test: �a W 24c.For Water SumAy&Injectiou Wells: In addition to sending the form to
the address(es) above, also submit I 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.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016