GW1-2021-02323_Well Construction - GW1_20210527

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Informatio
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1.! FROM TO DESCREMON
Well Contractor Name /
fL ft.
4Nq A
ft. R i
NC Well Contractor Certification Number 15,OUTER CASING for mat' ed wells ORiIiINEW& ble ,;';s g
I rOn�, FROM I TO DIAMETER Tffi MATERIAL
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JLL/ 1G INNER CASING.OR'3UBING "'t 1e ZQ
Co y Name 1
2$ iKrmt .:,
2.Well Construction Permit#:3 -FROM TO DIAMLTER TRICIUMS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) & fL 1n.
3.Well Use(check well use): &
Water Supply Well: 17.`SCREEN .. _ 'fit_w. i,,,e. F=`
FROM TO DIAMETER SLOT SIZE TMC'KNM I MATERIAL
Agricultural 13MunicipaUPublic 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) m2esidential Water Supply(single) ft. fL in, ji
Industrial/Commercial [31tesidential Water Supply(shared)
48.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft 0
Monitoring [)Recovery & ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19;SAND/GRAVEL PACK if a 'livable .
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage ft, &
Experimental Technology Subsidence Control It. ft.
Geothermal(Closed Loop) [3Tracer ;10.DRI 1 ING LOG attireti additionnl'sbeets'if
Geothermal(Heating/Cooling Return) i Other(explain under#21 Remarks) FROM TOnSRIMOx color,h ardness soil/rnrh size,etc
: 2-1 well m# t a
4.Date Well(s)Completed f
5a.Well Location: fL G
��ol✓I GS h y 7 A0 4 rl fL ft
Facility/� Facility ID#(if applicable) fr' f
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3563 R�a a �/�I f—�rl 14� f. ft.
Physical Address,City,an Zip / ft. ft ^ CCCLastrjll�
C7t�G(L1✓1 e 21"REMARIGS_. :P._ I"t3.3 ;t, r t
County Parcel Identification No.(PIN) kade 1 1/0-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iattlong is sufficient)
22.Certification:
N W 49� r�
6.Is(are)the well(s)dpermonent or Temporary Signature oCe fled Well Contractor ate
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or vfNo with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0100 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 or 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: Z�J (ft 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lit different(example-3@200 and 2@100') construction to the following:
10.Static water level below top of casing: (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 Injection Wells: In addition to sending the form to the address in 24a
d above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: T�
(i.e.auger,rotary,cable,direct push,etc.) r 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
r
13a.Yield(gpm) J Method of test:—&htlj 24c.For Water Sunnly&Injection Wells: In addition to sending the form to
the address(es) above, also submit one'copy of this form within 30 days of
_J
13b.Disinfection type: Amount4d _ 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