GW1-2021-05674_Well Construction - GW1_20210723

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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Well Contractor Name FROM I, I f rc DESCRIPTION �--)
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NC Well Contractor Certification Number
ORiMR CASIGformoltaed ER TO Sd a" MAbkT1 1•i_i;A..
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Company Name
16:INNER GASING.OR TUBING..
ahermal deeeda "._ ''
2.Well Construction Permit#: V W - ��� � r �(�O FROM To D1A1►>ET®t TslCiffvFss I MATERUL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL & 11n.
3.Well Use(check well use): ft' & in.
Water Supply Well: 1:17."SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) & fL in.
Industrial/Commercial Residential Water Supply(shared)
13.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 IL 6 is ore. iq 0 v re
Monitoring Recovery ft, &
Injection Well:
ft. R
Aquifer Recharge Groundwater Remediation
49.SAND/GRAVEL PACK if a livable
Aquifer Storage and Recovery OI Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control & ft,
Geothermal(Closed Loop) Tracer 2t1 DRnJ., CLOG attach additional aheets if r
Geothermal Heating/Cooling Return Other(explain under 421 Remarks) FROM TO DESCRLMON color,hardness,soilheek sire,etc.
p ft. 3 fL c SQ,r/
4.Date Well(s)Completed: �! Well ID# fr e ) ft. C toy
5a.Well Location:
Jc%h1,\q 13 mquney
Facility/Owner Name Facility ID#(ifapph.ble) & ft.
Physical Address,City,and Zip ft. &
W Q k e 2UREMARKSC.
County Parcel Identification No.(PIN) / e 6 r e�, Olt I ve— s t '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s)IPermanent or OTemporary Signature of Certified Well Cophactor 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: 0Yes or.[No with 15A NCAC 01C.0100 or 15A NCAC 02C.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#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 of 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:
(ft) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi�erent(example•3@2^^00'and 2@I00') construction to the following:
10.Static water level below top of casing: d (ft.) Division of Water Resources,'Information Processing Unit,
lfwater 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:
���-QC_ above,also submit one copy of this form within 30 days of completion of well
(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&IniectionLWells: 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: aTO 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 Resources Revised 2-22-2016