GW1-2021-05530_Well Construction - GW1_20211013

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
4 ;;WATER ZONES a`
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Well Contractor Name M TO DESCRIPTION
�COrQ�10q 9 ft. ft.
NC Well Contractor Certification Number Er p�r�� Ys OUTER: ASIIVG ro"F n to aseti:wells-OR`LIIVERf tt a ll&blE I v._­
FROM TO DIAMETER THICKNESS MATERIAL HI
(/V� •L4�' (�/( S I ✓�(. O ft ft. in.
Company Name
w I _ ©/ ? Atl-
­16.INNER CASING OR TUBING eotherdial`;cl&*d466i , .
2.Well Construction Permit#• /1� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i e.(1IC,County,State,Variance,etc.) ft. ft. *iq.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3M icipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) . esidential Water Supply(single) ft. ft. in.
Industrial/Commercial [3Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft.
'monitoring 'Recovery ft. ft. •
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
09sSAND/G",VELVACKi if.iWOlivable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology ®ISubsidence Control
Geothermal(Closed Loop) Tracer 20:DRILLINGLOGi attack additional sheets if irecesse"
Geothermal(Heating/CoolingReturn Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,soilhock size etc
ft. ft. ��-
4.Date Well(s)Completed: -- Well # ftI ft AJ
f- ID .
SCa./Well Location:q ft.
Facility/Owner Name Facili ID#(if applicable) ft.wig &h" ft.
ft. ft.
•
Physical Address,City,and Zie
Q Q ft. ft. t;l"
OSDy?��-!7�`.21 REMARKS °1"
County Parcel Identification No.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
156 11_ �o AV ZQ2 21
6.Is(are)the well(s) rmanent or Temporary Si tore of Certified Well C6 r i 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 0 with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
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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. Youjnay also;attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surfacer (ft.) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'rannd 2®100') construction to the following:
10.Static water level below top of casing: Z� (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. b (in.) 24b.For Iniection 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: K.C34 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) II,
Division of Water Resources,Underground'Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh',NC 27699-1636
13a.Yield(gpm) G� Method of test: �t9..IK For Water Supply&Iniedion 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:_H r kf Amount: U Q L4p,%"S 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