GW1-2021-05535_Well Construction - GW1_20211013

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
J 14.°WATER Zorrl?s
y Well Contractor Name �,-,8 FROM TO DESCRIPTION
NC Well Contractor Certification Number t�
UTBR CA5 G`till mu tl-cased:wells ORL NER"Iti llCeple *s:..
r t�JC"�
,, L/ , ` it.• �i, J� i�� FROM TO DIAMETER TEIICKNESS MATERIAL
in.
mpa Pile--
�!/
Cony Name
16.INNER CASING-OR TUBING(eothermel closed&ool
2.Well Construction Permit#: FROM I TO I DIAMETER I T MCKNESS I MATERIAL
List all applicable well construction permits(ie.UIC,County,State,Variance,etc.) ft• R• $fin
3.Well Use(check well use): ft. ft. im
Water Supply Well: 17r:SCREEN
FROM I TO DIAMETER I SLOT SI2Z THICKNESS f MATERIAL
Agricultural dZdce,1
ipal/Public 0 ft, ft, in.
r Geothermal(Heating/Cooling Supply) al Water Supply(single) ft. ft. in
Industrial/Commercial E3Residential Water Supply(shared) 1S:GROUT`
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft fL Ot
Monitoring DRecovery
Injection Well:
Aquifer Recharge E3Groundwater Remediation ft. ft.
11 :;19.SAND/GRAVEL`P,AGH a 'liceble :. .: ,
Aquifer Storage and Recovery E3Salinity Barrier FROM I To IMATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology Subsidence Control ft. fa
Geothermal(Closed Loop) Tracer 20 DRILLING.LOG'attach additional sheets N n
Geothermal eatin Conlin Return) Other(explain under#21 Remarks FROM TO DESCRIPTION eolor,hardness,sollfloek size,ete.
ft. tt
4.Date Well(s)Completed: 9-2D 1,1 Well m# ft. ft.
5a.Well Location: ft'
wtr�G S O/1! • / ft. ft.
Facility/Owner/ ��/�Name Facility ID#(if applicable)
P;1eC$0A
l Address,
City,and Zip fL ft.
'-
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient) p �,/ /— n 22.Ce ' cation:
--X0 Ss N 77 � ! �-6. 1 l W
/01
6.Is(are)the wells) ermanent or MTemporary Sign ah of Certified Well Con ! Date
�� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
ll�
7.U this a repair to an existing well: [3Yes or "" with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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.
23.5ite 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: SUBAT[T1'AL WSA0K=L0NS
9.Total well depth below land surface: f-ICJ (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q2000,'andd22@1001 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
1 above,also submit one copy of this iform 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 Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 0 Method of test:'-a tpc.For Water SnDDiv&Inlec ion 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: JU Amount: 10 0,24.124AS completion of well constriction tti 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