GW1-2021-03481_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information. R� „
rie- N Ca 6 C _ i4 WATER'ZONES
p . FgOM TO DESCRIPC[ON
Well Contractor Name 1 Al V 1 U fit ft.
d
is.-A v1! 'essl\ fL ti.
NC WeQ Cnnuactor Certification Number Mi0��CCv (1Q(� 35 OIITERCASING.for multi caved=wiDs:ORLIN[BR d` bk ;
�4rE�tl•: FROM TO D TEMCKNEss I M TERLA.
u��ran'r U�>•U� CO fL ft- in.
Company Name WINNER CASING'.OR'TiJBING `"tltermd did loo
2.Well Construction Permit#: ' 6-0 y 2110rd To I mAME1'Iat MATERLAL
List all applicable well construction permits#e.UIC,County,State,Variance,etc.) O & 1n.
3.Well Use(checkwell use): D' in.
water SupplyWell: M SCREEN
FROM TO DLedu dt orr s TE THICRrI&9S MATERIAL
cultural �unicipaVPublic flu. R in. b
Geothermal(Heating(Cooling Supply) Residential Water Supply(single) ft. fL in.
Industrial/Commercial Residential Water Supply(shared) IS.GROUT
Ini 'on FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (� fi. 0 R e G ne
Monitoring Recovery ft. R
Injection Well:
ft R
Aquifer Recharge DGroundwater Remediation
I9:'SA�ND/GRAVEEPACK d . .sabtc
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERMI EMPLACEMEW METHOD
quifer Test OStormwater Drainage &
Experimental Technology Subsidence Control tt. %
Geothermal(Closed Loop) Tracer 20.=DRni ING LOG'atti►cb additionefabeets'if:'
Geothermal(HeatingtConlin Return) MOther(explain under#21 Remarks I•AOM To DESCRIPTION color,hwftea,s6Vrodc do
4.Date Well(s)Completed: well ID# a 0 L(G
5a.Well Location: 0 ft ,4 fL 4 t✓
S4ft ft
Facility/Owner Name Facility ID#(if ap livable) ft. ft
cro(-kcr_3 nKb ft. fL
Physical Address,City,and Tip R ft.
JGn a.4 71 REMARres 1
County Parcel Identification No.(PIN) t t� 4~ `V't (!t-
5b.Latitude and longitude in degrees/minutestseconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N WBr,Jtt�' �— —
6.Is(are)the wells) Permanent or 13Temporary Sigoatme of Certified Well Contractor 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: 13Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction standards and that a
IjiMs is a repair,fill out known well construction information and explain the no.of the copy 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 site details or well
construction,only I GW-I 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: G�� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@260 and 2@100') construction to the following:
10.Static water level below top of casing: ff
lfwater level is above casing,use"+^ � � ( ) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sanding the form to the address in 24a
12.Well construction method: AOf-dri above,also submit one copy of this Iform within 30 days of completion of well
construction to the followin
0-a.auger,rotary,cable,direct push,etc.) g'
n
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 6 Method of test: r7W 24c.For Water Suppiv&
-in fection Wells: f In addition to sending the form to
gotthe address(es) above, also submit Jone 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-1 Nanh Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016