GW1-2021-01655_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD(GA-1) For Internal Use Only:
i.Well Contractor Information: ("�®�J
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Well Contractor Name . TO DESCRIPTION
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NC Well Contractor Certification Number
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Company Name ^�l ND 16 d E riN
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2.Well Construction Permit#: J( S FFRTO DUME M 'I> CKNEss MATERL►L
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) ft.
R• in.
3.Well Use(check well use): ft• in.
Water Supply Well: TO InU x sLUrSUZ THICKKESS M❑Agricultural ❑Municipal/Public ft. in.
❑Geothermal(Heating/Cooling Supply) Cdkesdential Water Supply(smg1e) tt
❑Industrial/Commercial ❑Residential Water Supply(shared) .
Dlrriaation ❑Wells>100,000 GPD FROM TO MATERIAL F101 ACEM11M METHOD&AMOUNT
Non-Water Supply Well: 6 ft. �2-0 it. do-
❑Monitoring ❑Recovery it. fL
Injection Well: fL it.
[]Aquifer Recharge ❑Groundwater Remediation
;19.�SAND/GRitV:EI.�P.EiCiC �" `�fe�h. -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERUL EMPLACEMIM N=01)
❑Aquifer Test ❑Stormwater Drainage fL
❑Experimental Technology ❑Subsidence Control ft. fL
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❑Geothermal(Closed Loop) ❑Tracer 20:=DRR!JNG"L0G'itb"4ddttieoil`atiEetigt T
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color hft wiYmek era
ft, Z ft. G OL '
4.Date Well(s)Completed: I �' Well ID# Z ft 3 iL Sa11 d S d
Sa.Well Location: 3 fL � fL
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Facility/Owner Name Facility ID#(if applicable) % R
9© 1'_aa iS-Ak� I n, Lou►s" fL fL
Physical ddres�d Zip l ft. ft.
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County Parcel rdentification No.(PIN) u /W
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
/ N W
IRP /y ZOZ
6.Is(are)the well(s): ermsnent or ❑Temporary Signature of CertilTed Well Contractor Urate
By signing this form,I hereby certify that the well(s)wns(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or dNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform.
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 construction info
construction,only 1 GW-1 is needed Indicate TOTAL NUMBER of wells (�'�Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: � 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 24v"' (ft-)
For multiple wells list all depths if different(example-�3@200'and 2Q100� Submit this GW 1 within 30 days of well completion per the following:
ater level below top of casing: ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static w
If water level a erabove caring,use op Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter 6 (in.) 24b.For Injection Wells:Copy to'DWR,Underground Injection Control(IUC)
r Program,1636 MSC,Raleigh,NC 27699-1636
1L Well construction method: fart 24c.For Water Saw and Open-Loop_Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable direct push ear.) county environmental health department of the county where mstalled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water!� Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: Amount: /iQ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018