GW1-2021-01015_Well Construction - GW1_20210419

W- For Internal Use Only:
WELL CONSTRUCTION RECORD(G 1) y
1.Well Contractor Information,
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Well Contractor Name r FROM TO DESCRIPTION
r� 1 g 2p21 S ft. ft. �
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NC Well Contractor Certification Number N Itl1i v 3 "
rg11`i� 15.�©UTER.tiliSING or.�aiH� r;M:w"'�s UR�.Il�1FR. ble,
FROM TO DIAMETER THICKNESS MATERIAL
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Company Name J� fL ft. 6 In'
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2.Well Construction Permit M. /52 FROM I To I DIAMETER THICKNESS MATERIAL
List all applicable wrll construction permits(Le.UIC,County,State.Variance,etc.) ft• fL in.
3.Well Use(check well use): ft• ft. in
Water Supply Well:
PP y FROM TO I DIAMETER SLOT S12Z I THICKNESS I MATERIAL
❑Agricultural ❑Murnicipal/Public fL tt.
❑Geothermal(Heating/Cooling Supply) C1esidential Water Supply(single) ft• ft. is
❑lndusttial/Commercial ❑Residential Water Supply(shared) SGIt4.UT ..
01trigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: L12 ft. ;�o ft 4 091 poor
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aqutifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer b20 DDRH%WG-L0G,iittiiWa"ddie[bonlglceets�f,Blces
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❑Geothermal(Heating/CoolingFROM TO DESCRIPTION color,hudn sell(mch Return ❑Other(explain under#21 Remarks U & 3 u ft- G
2"4.Date Well(s)Completed: )-6 We 11ID#
ft S71r ft S QTi
5a.Well lion: s� ft FJ
Facility/Owner Name Facility ID#(if applicable) ft. ft.
301g3 14LIA 1/0 If Y DL f- ft.
Physical Address,�+Cityp,and Zip ft. ft.
County Parcel Identification No.(PIN) a� ,�z(✓2
5b.Latitude and longitude In degrees(minutes/seconds or decimal degrees:
(if well field,one lat(long is sufficient) 22.Certification:
N W 3 ��
6.Is(are)the well(s): permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,I hereby certify that the w+eB(s)was(were)constructed in accordance with
7..Is this a repair to an existing well: ❑Yes or I No 15A NCAC 02C.0100 or 15.4 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 GeoprobelDPT 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 Over'in Remarks Box).You may also attach additional pages if necessary.
filled' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ( ) Submit this GW-1 within 30 days of,well completion per the following:
For multiple wells list all depths if different(eumnp e-/3@200'and 2@1001
10.Static water level below top of casing: 7 ( ) 24a. For All Wells: Original form,to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+-
11.Borehole diameter: b (�,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
1L Well construction method: lZo�a�`�c 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county enviromnhealth department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) J6,/ Permit Program,1611 MSC,Raleigh,NC 27699-1611
Method of test: 6
136.Disinfection type: Amount: as
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2018