GW1-2021-05524_Well Construction - GW1_20210901

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
i,Well Cctor Information:o a
fthup
WeIlContractorName d FROM TO DESCRIPTION
6 ,, ..� tl� >< ft. ft.
4���j _. y�� `Jl�tt t
p„�n,�=�f e �,i� ft. Q ft dyl
NC Well Contractor Certification Number �i1SvCt. r_ t;011
/ w ;A115 D R ar nbItiv` 31 fdNF#i;: live
g OR' PROM TO DIAMETER THICKNESS MATERIAL-
(°' 0 ft. IL ft. in g V A
Company Name j a
NJ
n1~6:�11R�' <t1R'1 tiR #ti ea�l`�l(rsed-la
2.Well Construction Permit#: J. -7 1. FR°M TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in,
3.Well Use(check well use): ft in.
Water Supply Well: 7,Stt11 , ,;'T'.
FROM I TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL a
Agricultural [3MunicipaltPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) aResidential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared) 11tr
Irrigation FROM TO MATERIAL _. EMPLACEMENT METHOD&AMOUNT}
Non-Water Supply Well: b, D ft.
A MIN
Monitoring Recovery ft. it.
Injection Well: ft, &
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage
Experimental Technology Subsidence Control ft, fL
Geothermal(Closed Loop) Tracer 20:1) G'Gf3 atttir h ' itbti 's7ifsefs t}ri a ?;.v:
Geothermal eatin Cooling Return Other(explain under#21 Remarks FROM TO D SCRTMON color,hardness,softfrock in ata eta
ft. ft. y'
4.Date Well(s)Completed: r �7� ( Well ID# W ft- ft. tY.
5a.We Location: (00 ft. it.
012 'lldr Ua ft. 0 ft.
Facility/OwnerN a acilityID..#tt(ifapplicable) ft. ft.
Ali2 . # .f 0A 14 C )T ft. ft.
Physical Address,C'y,anyd� ip ft. ft.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latnong is sufficient) 2 rtiftcation:
N W
6.Is(are)the wells) Permanent or �Tempa;No
y Si of Certified c C tract Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes of with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 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
construct'on,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: `�C SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ✓.J t A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3Q200'and 2(Qa 100`) construction to the following:
10.Static water level below tap of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service tenter,Raleigh,NC 276994617
11.Borehole diameter: (in.) r 24b,For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: _.— construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resourcesi Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)_ © Method of test: 24c.For Water SuDDIv&Infection Wells: In addition to sending the form to
1_ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to'the county health department of the county
where constructed.
I
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016