GW1-2021-06587_Well Construction - GW1_20211029

WELL CONSTRUCTION RECORD (GW-1) For internal Use :On1Y
1.Well Contractor Information:
0 2 ftz, y 14.-WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
NC Well Contractor Certification Number
`..15::OUTER CASING ftir<multi-eAseil`welis ;OR LINER if-a"-licable _
=IJBING46—th—.10
DIAMETER THICKNESS MATERIAL
Compa�Name \J 7 l3 in.
7 J� osed too"
2.Well Construction Permit#• .,J / 73 4! FROM TO DIAMETER THI NESS MATERI L.
List all applicable well construction permits(i.e.UIC.Count.Stale, Variance,etc.) ft. D�ft. in. 7s
3.Well Use(check well use): [t. V ft. in. U
r
ply Well: .17.SC.REEN, .
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ral Q unicipaVPublic ft. f in:
al(Heating/Cooling Supply) Residential Water Supply(single)
ft. t. in.
Commercial (... Residential Water Supply(shared)
18s;GROUT >.
FROM TO MATE IAL EMPLACE NTMETHOD&AMOUNT Supply Well: ft ft. Sg QRecovery
Injection Well:
A uifer Recharge ft. [t
q g E)Groundwater Remediation
Aquifer Storage and Recovery Salini Barrier 19.SAND/GRAVEL PA it a` licable
tJ' tY FROM TO MATERIAL F,MPLACEMENTMFTHOD
Aquifer Test DStonuwater Drainage
i Experimental Technology DSubsidence Control it. ' f
r'Geothermal(Closed Loop) DTracer 610.`DMLLING:LpGi ttach additionahsheetsif necessar
i Geothermal(Heating/Cooling Return) ;"` Other(ex lain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilfroek type,grain Size,etc.)
ft. ft. , A
4.Date Well(s)Completed: Well iD# ft
C • ft.
3✓ 7'1 f C
5a.Well Location: I f ft. tj J"
leld 2- I I C fZeeK D✓ ABC �l ft. 0 Oft. ;
\`Facilit /Owi ie bt. q fL
JJJ" Y Naat, Facility ID#(if applicable) j� i
ft. ft. N 5—i
i
Physical)Address,City,and
Zip ft ft. 9 (�
CAP+e f C`E— 21.-REMARKS.. ;
County Parcel Identification No.(PIN) �'mt 3i?cn-'14I�I�rv�>°iF,} '
r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient)
22.Ce (cation:
3q ll�,t �� N 7& �3�2z�5 W
6.Is(are)the well(s)�ya Permanent or Temporary aturc of Certified Well Contras: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: E)Yes orXXxplain
o with 15A NCAC 02C.0100 nr 15A NCAC 02C.0200 Well Constntction Standards and that a
//this it a repair,fill out known well construction hfanation the nature ofthe copy gjrhis record has been provided to the well owner.
repair under#21 rentarks section or on the back o/thi.s(arm.
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 ned. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: jn� � SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ff.) 24a. For All Wells: Submit this form within 30 days of completion of well
For n:u/tiple wells list all depths ifdiiferew(e-rample-3@ 00'and/,2 tt 100') construction to the following:
10.Static water level below top of casing: C� Division of Water Resources,information Processing Unit ifwater level is above casing,use'+" + g ,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (In.) 24b.For infection Wells: in addition to sending the form to the address in 24a
12.Well construction method: '-I /C 2 above, also submit one copy of this IForm within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following: f
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 7 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) � Method of test: �/ 24c. For Water SuppIV& infection 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:c o &/�z Amount: completion of well construction to the county health department of the county
where constructed. i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016