GW1-2021-05493_Well Construction - GW1_20211013

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WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.W:v Contractor Information: I
14.WATER ZONES
Well Contractor Name t�( �— Ul,,� FROM TO DESCRIPTION
` � > tlll•
5, 9 n. ac -111n f.
ry���aNC'Well Contractor Certification Number p fftt..
is.OUTER CASING for multi-cased wells OR LINERif Iicabie
©® @ FROM TO I DIAMETER THICKNESS MATERIAL
Company Name v
16.INNER CASING OR TUBING eothermal closed-loon)
2.Well Construction Permit#: Q 1 l + 9_ ) I(J FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits ri.e.UIC,County,State,Vari&ke,etc.) 0 ft to It. In. V G
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN .
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural E]MunicipallPublic ft,
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. tt. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. Z O ft r QV 1
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Rcmediation 19:5ANDiGRAVEL PAGiC f a Iicable
?Iquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage fI ' .
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer .20.DRILLING LOG.attach additionatsheets Tnecessa
Geothermal(Heating/Cooling Return) Other lain under#21 Remarks FROM TO DESCRIPIION color hardn soil/rack type,grain si eta
0 ft. 'a ft.
4.Date Well(s)Completed: J- G�l Well ID# a ft. 6 L'Q ft. roriliff 1,0 L C
5a.Well Location:
6 I ft. ft
Facility/ Name �ac''ty J#(ifapplicable
60
Physical dress,City,and Zip ft.A ft.
�.•!}�G yyt' 21.REMARKS- I
County 11�, Parcel Identification No.(PRT) 16 d £ Lynl
/a( `
fo
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: S tcl ff G f2tedn
(ifwell field,one ladlong is sufficient) 22. tiflcaflon:
N W IW�1'1 e
6.Ls(are)the well(s) . Permanent or Temporary i re of C&fi ed Well n i
signing this form,I hereby certify that the well(v)was(were)7.Is this a repair to an existing well: []Yes or JNo with 15ANCACO2C.0100orI5ANCAC01C.0100 WellConstr
(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 421 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
constructiorp,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also;attach additional pages if necessary.
filled' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: d (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection 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: 1 67-t V`
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,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 Supply&Injection 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: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016