GW1-2021-04279_Well Construction - GW1_20210901

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor J Information: =�,Vs ppoo�F i4::1niTAI E1tr2
Well Contractor Name A' FROM TO DESCRIPTION
,l 1 24�1 ft. ft.
21�� tj jilt ft. ft
NC Well Contractor Certification Number >t"
15;ff lTFrlt'CA'S1l+l ot flRT,1NEli HcsBle'
Gera ( o a I n FROM TO DIAMETER THICKNESS MATERIAL
/� ft. ft in CI a
Company Name V U
}� i1tx C R TtiB t6'er�tial'ci5cedlo
2.Well Construction Permit#: AQ,& �M 11-3 1 FROM TO DIAMETER THICKMS I MATERIAL
List all applicable well construction perhits ri.e. UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): it. it. in.
Water Silpply Well: _. ,'. .,, ;: r ,:<:_
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public it, it. In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. fL in.
Industrial/Commercial Residential Water Supply(shared) Al
�pp /fitt
Geothermal
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. tt. a VA 1 4 V
Monitoring . Recovery
Injection Well:
Aquifer Recharge E3 Groundwater Remediation
if_A*tvn1 ' ttJr
Aquifer Storage and Recovery 13 Salinity Barrier FROM TO MATERIAL s EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control
Geothermal(Closed Loop) 13Tracer z 20.,V1MX1N0t6G ftael ddltloi 3beetsiftec s ,;a
Geothermal(Heating/Cooling Return) r3Other(explain under#21 Remarks FROM To DESCRIPTION color,hardness saftock in sl etc.
�( ft. a ft. C" d
4.Date Well(s)Completed: v -a I Well EM ft' it' b(,k,
ft. it.
5a.Well Location:
ft ft.
hot na Rt-r-4 o
Facility/Owner Name Facility ID#(if applicable)
Physical Address,City,and Zip
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlong is sufficient) 22.Certifl lion:
N W 8
6.Is(are)the well(s) Permanent or Temporary Signature Certified Wet. or 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: ®Yes or E6No with 15A NCAC 01C.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
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 0 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: O (ft-) 24a. For Ali Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths if different(example-3@20000'and 2@I00) construction to the following:
10.Static water level below top of casing: 0 (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: M•) 24b.For Injection Wells: In addition to sending the form to the address in 24a
I� above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: CD I'A✓� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) `F Method of test: I W 24c.For Water SuoDly&Iniection 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 toC 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