GW1-2021-05644_Well Construction - GW1_20210723

WELL CONSTRUCTION RECORD(GW-1). For Intemal Use Only:
1.Well Contras Information:
14 WATER ZONES
FROM - TO DESCRIPTION
Well Contractor Name
�o y 2 ��� �� ft ft. `t.
NC Well Cottttactar C ' cation Number 2021 I5.OUTER.CASING'for min d wells)OR
LINER rf a "
S 1U� �pd J Ur1 FROM TO DIAMETER THICIWESS MATERIAL
Company Name J (�1rrtCB 4n� fL rfL in. ./1V
/)7 f�q`� 1� C r,t;01ti 16::IIVN)€R:CASII�TGUlt:TLlBING: closed-loo 2.Well Construction Permit#: 1 ! '' vet FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft in
3.Well Use(check well use): R' 1O
Water Supply Well: FROM I TO DIAMETER! SLOT SIZE THICKNESS MATERIAL
Agricultural [3Mtmici al/Public O ft ft in
Geothermal(Heating/Cooling Supply) 519idential Water Supply(single) ft in
Industrial/Commercial Residential Water Supply(shared) 18.GRUIFF
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 o ft ., Z �(�
Monitoring DRecovery ft ft.
Injection Weil: ft ft
Aquifer Recharge 13Groundwater Remediation 19:S4,ND/G1tAV£L'PA1CR'- ble
Aquifer Storage and Recovery [,Salinity Barrier FROM TO MATERLIL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage & ft
Experimental Technology Subsidence Control ft
Geothermal(Closed Loop) Tracer ':36s-DRIILLJNG:LOG.. ant"wtudabbetsAfnecemm
da f ".
Geothermal(Heatin Conlin ) MOther(explain under 921 Remarks FROM I TO DESCRIPTION color,hardness,s*Wrock sue,etc
O & n rr
4.Date Well(s)Completed: Well ID# /90 ft 1 '-3 d
d C
Sa.We Location: ft' t'
�,� ft ft
Facility/Owner Name A Facility ID#(if applicable) ft ft./
V 3 k �- �"/ Z & f
Physi City,and Zap ft ft
_21:REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,out lat/long is sufficient) 22.Certification:
W 1.9-0 o�
6.Is(are)the weil(s) ermancut or Temporary Signature of r - Date
� By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [)Yes or l.C3"o with 15A NCAC 02C.0100 or ISA NCAC 01C.0200 Well Construction Standards and that a
If this is a-pair,fill out known well construction information and,=plain the native of the copy of this record has been provided to the well owner.
repair under 921 remarla 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 -nstr+ction details. You may also attach additional pages if necessary.
drilled:
�7 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J 0 For multiple (fr) Z4a F All Welts: Submit this form within 30 days of completion of well
cons wells list all depths ifeifferent(example-3()a 200'�annd 2 a@100� 24a. or or A to the following:
10.Static water level below bop of casing: J (fL) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
above,also submit one copy of this form within 30 days of completion of well
�� Gt f
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
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: 24c. For Water Supply&Infection 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: 7-# Amount: completion of well construction',to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resoutces Revised 2-22-2016