GW1-2021-06839_Well Construction - GW1_20210419

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Weil Contractor Iaf r�o�
[f// '14r�WATER"ZONES
FROM TO I DESCRIPTI N `
Well Contractor Name ;�p al �y 7 ft. tt
ft. ft.
NC W]l Contractor Certification Number (� r/�021 15 Ul11ER GtSIN6 foe mold cased w ORIINER;sf'a'" cable `s
FROM TO 1 D R I THICCKNESS) MATEHA►L
'v/✓ ylti h ft. ft in.
Company Name Q/
� �1 t I`' �16�1NNER CASING"011T[JBING ""flKi'm`al!clmedaoo S' .
J + v 2.Well Construction Permit Ifa rrY'0� FROM TO DIAMETER THICKNESS MATERIAL
#: /�� 1+� •:1,,.�.v'
List all applicable well construction permits(.e.UIC,County,Slate,Variance,etc) ft. It. in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well:
FROM TO .DIAMLTER„..-SLOT SUE THICKNESS ' 'MATERAAr,
Agricultural [IMunicipal/Public 0 ft. & in.
i Geothemtal(Heating/Cooling Supply) Residential Water Supply(single) & fit. In
Ind 'aVCommercial Residential Water Supply(shared)
-..-
atlOn FROM To TtatIAL W11100&AMOUNT
Non-Water Supply Well: R
_,'Monitoring DRecovery ft & /
Injection Well:
ft tt
Aquifer Recharge E)Groundwater Remediation 19:`==.SAND/GReCVEI;:PACIC f Ilcalile
_- Aquifer Storage and Recovery E3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test o Stormwater Drainage &
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) OTracer 20 DRILLING T OG;atdich addltionafvieets ie. ", ' T 7,77777
Geothermal(Heating/Cooling Retum Other(explain under#21 Remarks) FROM TO D o odor Iwd oNmck etc
_ i
f JR
4.Date Well(s)Completed:/ Well ID# ft ft. - G.
5a.Well Location: y-y ft. P ft
ft. J!.�� ft.
Facil�itty//'Oww�nerName I�/ l Facility lD#,(iiffappliccable)/�/�r fL ft.
�// D'4 1 , )1 feU` ld A1- e V/l/�Ci" /i - ft. It.
Physical Adddrreess5ity,and Zip ft. It
e/40 ) 21 REMAR"
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
0 22.Ce&Ication:
' N I /J � � W37 / '449' 4 a&'
6.Is(are)the well(s) rmanent or OTempurary Signature ofCaffied Well Contractor Date
By signing this form,I hereby cerafy that;the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or 01'roo with ISA NCAC 01C.01W or ISA NCAC 02C.02W Nell Construction&an*n*and that a
If this is a repair,fill out known well construction information and explain the nature of the copy ofthis record has been provided to the well owtrer
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: ;?Jo p ' (ft.) 249.For AN Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferem(example-3 290''and 2@1061 construction to the following:
10.Static water level below top of casing: 62 Z (ft.) Division of Water Resources,Information Processing Unit,
If water level is above easing use'+^ 1617 MaI!Service Center,Raleigh,NC 276"-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
j� above,also submit one copy of this`form within 30 days of completion of well
12.Well construction method: ��1//' construction to the following:
(ie.auger,rotary,cable,direct push,etc.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ) l 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of testa� r�167
24c.For Water Suppiv&Iniectio Wells: 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: / Amount:62?A completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016