GW1-2021-01656_Well Construction - GW1_20210429

\ WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Info ad a- � ®
DESCRIPTION
Well Contractor Name a � TO
�f1V tt 4, ft. 1/z
36� P�� co�� ft. ft.
NC Well Contractor Certification Number �e �6 .15 AUT9KVASING.forfiialH ailed. d13
FROM TO DIAMETER THICK NIM MATERIAL
.€� f-l �• 22 �• 6 '°. , (�� Cif� ;
Company NameFROM
TMo
2.Well Construction Permit
List all applicable well construction permits(t e.UIC,County,State,Variance,etc) fL it. in.
3.Well Use(check well use): ft ft.
Water Supply Well: FRO TO D�IA 1�>EM x➢SNOT s z �rmCKaNU s MATERML
❑Agricultural ❑�/Municipal/Public fL ft in.
❑Geothermal Mcating/Cooling Supply) IrJResidential Water Supply(single) ft• it• in
❑Industrial/Commercial ❑Residential Water Supply(shared)
DIrrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMEINT METHOD&AMOUNT
Non-Water Supply Well: Q ft. ZC)ft. 011 f
❑Monitoring ❑Recovery fL it.
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.YSANDJG1tifYEL�P:CCIC' c .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEM M METHOD
❑Aquifer Test ❑Stonnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. IL
❑Geothermal(Closed Loop) ❑Tracer 20sDRI13tiING:130G.ittiiehadBtHeiil5heeta
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) FROM TO DFSCM>p'I'r la ON color,hu wlurock ere
p a ft 2 ft. I
4.Date Wel(s)Completed: 2 l Well ID# 2 it U� & de
5a.Well Location
fI p ft
Facility/Owner Name Facility ID#(if applicable) ft ft
Ph -cal Address,City,and Zip ft. fL21E�REMARRS'.,<'
county Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W �/� ZcJ2�
6.Is(are)the well(s): mPermanent or ❑Temporary Signature of Certified VVell Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 111�4o 1 SA NCAC 02C.0100 or 1 SA 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 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
filled' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: *,X- _(fL) Submit this GW-1 within 30 days of we0 completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100)
10.Static water level below top of casing: 66 I ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If venter level is above easing use/"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter y (in.) Program,
For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
IL Well construction method: "a� 24e.For Water Supply and Open-Loo Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: nn r 24d.For Water Wells producine over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 2 Method of test: D I Uhhv) Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:J H1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-62018