GW1-2021-06043_Well Construction - GW1_20210901

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.`Well Coniractor Information:
Well Contractor Name tl
FROM TO DESCRIPTIONnil "
S r� Aft, �(� ft, i
iarn,C£?`Sii$J i 1iZ1 ft.
ic
NC Well Contractor Certification Number - V � i,U t ;.,QLil Eft
Grad-,
no (/,�.. FROM TO DIAMETER! THICKNESS MATERIAL
fG 1Y ft ft. lin.
Company Name �y f6' C145'11 CtilYlil I�f3B G. ' oEkatdi ciasedlbo _.
. FROM TO DIAMETER THICIINESS MATERIAL 5
2.Well Construction Permit#-. tt• ft• in,
List all applicable well construction permits(1.e.UIC,County,State,Variance,etc)
tt. fL tn.
3.Well Use(check well use): ;
Water Supply Well: FROM TO DIAMETER ,SLOT SITE THICKNF&S MATERIAL
Agricultural rLlWuncipalftblic
Geothermal(Heating/Cooling Supply) oResidential Water Supply(single) fL ft. in.
Residential Water Supply(shared) 1$ (1T1T
Industrial/Commercial „•`: " �'`'. `` "' "
FROM TO t.. MATERIAL EMPLACEMENT METHOD&AMOUNT.
Irrigation
Non-Water Supply Well:
Monitoring Recovery
Infection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation -
'�'1�� ' 7G�AYBLYAd��ii Ui�t►1e ., :. ...,� .. -:,•.
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test
OStomtwater Drainage tt. •
Experimental Technology OSubsidence Control tt s
Geothermal(Closed Loop) OTracer a`VRO1%1211#rI IAIfiO tlG attteEti DESCRI ION coltttecets
FROM TO DESCRIPTION color hordeem soiUrack ri in size,etc,
Geothermal(Heating/Coolin Return Other(explain under#21 Remarks) o ft. 2
le-
4.Date Well(s)Completed: V 'a Weti ID# it• $ ft.
ft. ft
SaA.Well Location:
:
A)1�`!c a'e ft. ft
Facility/Owner Name Facility M#(if applicable)
ft. ft.
a d 1 nl e xi �� �jgnA i 14 J• ft. tt•
Physical Address,City,and Zip s
A ltr. k O a� �,-1LEi•SA.RRS -
County arcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one laviong is sufficient) 22. tit-ieation
N W 8 Z ZI
t a ertrfied a or Date
6.Is(are)the well(s) Permanent or OTemporary
By ing this form,I hereby cert{fy that the xell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or J%No with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Constniction Standards and that a
copy of this record has been provided to the well owner.
this is a repair,fill out known well construction information and explain the nature of the
If
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 i GW-i is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: QQ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: O 00 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@1001 construction to the following:
to.Static water level below top of casing: 2x� (ft.) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
ejwater level is above casing,
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
ro
y� above, also submit one copy of this;form within 30 days of completion of well
12.Well construction method: 14 i/ I construction to the following: .
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Infection Control Program,
FOR WATER SUPPLY WELLSONLY: f ;9,4 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) " _ Method of test: `,w 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also subrhit!one copy of this form within 30 days of
13b.Disinfection type: Amount: 11 completion of well construction to;the county health department of the county
where constructed. I
f
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourc i Revised 2-22-2016
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