GW1-2021-04167_Well Construction - GW1_20210827

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Info�rmmation:
-
-�"�'--� FROM r0 DESCRIPTIOY
Well ContractorName
� ) V—
NC Well Contractor Certification Number >✓O
TERML
�//. ,15:'.OIITER:CASING foi:iri` {reiedwelib'OR`]fIIUER
/l//�G II (J 0'�OS. �AG t FROM TO DIUWER i THICKNESS MA
I tt. /s�L ft. in. �'OR
G .
mpanyName
F 9 Y ulWINtUER'CASING OR:TOBMG' eoth8emst elumed400
2.Well Construction Permit#: /Q U` I A FROM - To DIaMErER' THICKIMS I MATERIAL.
List all applicable shell construction pe-dis(Le.WC County,State,Variance eta) fL ft. in.
3.Well Use(check well use): ft. ft. In.,
Water Supply Well: 1Z S13tEENs>.tsa. r R t, s1+.3<:E; :>w:?r: ssis :« r ;.:"x_
FROM TO DIAbIEFU SLUM= TMCKNESS.,..,+MAXERIAL`
L
OMunicipaftblic t) & ft.
al(Heating/Cooling Supply) Residential Water Supply(single) % &l/Commercial [3Residential Water Supply(shared) FROM To MATERIAL EMPI.ACEMENTMETHOD&AMOUNT'
Non-Water Supply Well: ft. R v; d Af
Monitoring ORecovery tl: is 61
Injection Well: ft ON
::
Aquifer Recharge [}Groundwater Remediation
99:SANDlGRAVEGPACK' a""'Ise6ble °';l!%`,:+t:a`:::ai�a:`rE."'k:/G:ac:r:}':iF:_fi:i.`•:is,%1Y(`S@
Aquifer Storage and Recovery Salinity Banier FROM TO MATERUtt EMPIACEIItENT METMOD
AquiferTest OStonawaterDminage R
Experimental Technology Subsidence Control is
Geothermal(Closed Loop) Tracer 20.'DRIL7.BUGLOG aNaeti:0ditiou6labeets'ir'_._..__.._ .. ,_:.•_._.
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM To DESCRH'TION minor sdUsoetc as
�j tG ft.
4.Date Well(s)Completed: ` L Well ID# f t' Z�
5a.Well Location: 3 z,!L J r—a—a n'
Facility/OwnerName - Facility ID#(ifapplkable) fL 7OZI ft'
y fa fa ,
/
Physical Address,City,and Zip Z!O % ft. '
f�e r✓ ,7�1—J/Z "S `� 21iRF1VIARK3" F r..; ,,e;t. .. t a
County Parcel Identification No.(PIt� 1 tilCt`j.
5b.Latitude an longitude in degrees/minutes/seconds or decimal degrees:
(ifwcU field,one latQong is sufficient) 22.Certification:
e
3 S'6 7, 3 Y, r9 N S1 D -5 j 7 ;2 S-2 it W 21,P-44-9/
6.lKstre)the*11(s)CI•PCimanent or Temporary Si ofcadfied i Contractor Date
Sy slgntng this form,I hereby eer*that,the well(s)was(were)constructed in accordance
7-IS this a reps it to nn existing well: r3Yes or eli! with 15A NCAC 02C.01W or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifdds is a rrpatr,)U1 out Imoun well construction Wormation and explain the nature ofthe aopyofthtr record has beenprovided to the srepoimer.
repair under#2I remarks section or on the back ofthisform.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of".page to provide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells consttuction details. You may also attach additional pages if necessary.
drilled: — SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 24a.For All Wells: Submit this form within 30 days of completion of well
Farmultlp/e wells list all depths tfd/fferert&=mp/e-3@20�0—and 2@100 construction to the following:
10.Static water level below top of casing: J (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level Is above casing:use"+- 1617 Masi Service Center,Rafelgh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
99
above,also submit one copy of this'form within 30 days of completion of well
12.Well construction method: R ej-Aoy construction to the following:
(i.e.auger.rotary.cable,direct push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raletgb,NC 276994636
13a.Yield(gpm) Method of test: ►' ' 24c.For Water SunDly&Infectio i Wells: I addition to sending the form to
/ the address(es) above, also submit!one copy of this'form within 30,days of
13b.Disinfection type:el2Id r,')I t- Amount: J Z , completion of well construction to`the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources l Revised 2-22 2016
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