GW1-2021-06684_Well Construction - GW1_20211007

W-1 For Internal Use Only:
WELL CONSTRUCTION RECORD(G ) Y
1.Well Contractor Information: 9 '®
JA k-Sts�� �1 FROM TO DFSCRIPfION
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Well Contractor Name O b� l ft. ' a
ft. ft.
NC Well Contractor Certification Number (� ;CC1
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fO� C �� ^\�L`6� oLl��� FROM TO DIAMETER TffiCidiF88 MATERIAL
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Company Name n
16;31VNER=_GASIN"WN UBING: t6e[mah a
2.Well Construction Permit#: lft4v FROM To DIaMLTER THICKNESS MAIBRiAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL ft' iO
3.Well Use(check well use): ft-
>.17.�SGRE1•;N
Water Supply wen: FROM I TO DIAMETER SLOT SiZE I THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. 1 �960ft, in. t SG
❑Geothermal(Heating/Cooling Supply) Me—sidential Water Supply(single) ft. ft. is
❑lndusttial/Commercial ❑Residential Water Supply(shared)
oirrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMK.ACKMENT ME OD A AMo1JNT
Non-Water Supply Well: U itIn
ft 4ckl (u O(We
❑Monitoring ❑Recovery ft. ft
Injection Well: ft. IL
❑Aquifer Recharge ❑Groundwater Remediation
/GILAVII.�IPAGK? tit6"
y:
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMFLACEMIM METHOD
❑Aquifer Test ❑Stormwater Drainage it. M
❑Experimental Technology ❑Subsidence Control & fL
❑Geothermal(Closed Loop) []Tracer 20.DRHAMG LUGAttachiiiddIdotuii
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,luudn toWrock etc.
�ry d it. it G �SoJ`
4.Date Well(s)Completed: 'd / Wen ID# ft- a Q it. &-
Sa.Well Location: '()it. 'g� tt- S
��a✓t►�Oh I-b0QS fL 13,0S'ft`
Facility/owner Name Facility ID#(if applicable) ft, %
t5-/2, G h o( (` a fL ft.
Physical Address,City,and Zip ft M
�,LR1tsCi-
county Parcel Identification No.(PIN)
1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 2' lilC d� 'l r�`l
6.Is(are)the well(s): ©Permanent or ❑Temporary Signature of Certified ell Contr 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 &K-0 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Shmdardr and that a copy
Ifthis 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 1c,provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
filled' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: G',7J (fL) Submit this GW-1 within 30 daysof well completion r the folio
For multiple wells list all depths if different(example-3Q200'and 2®100� ��'
10.Static water level below top of casing: C) (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifxnter level is above casing use„+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: /lo (in,) 24b.For Injection Wells:Copy to1DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12 Weil rnnstraction method: @ t r✓ r/ 24c.For Water SapDly and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.) county-environmental ealth department of the county where'—Ilea
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing ovei 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) V Method of test: )j✓ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: )-T rA - Amount: f
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 6(r201 S