GW1-2021-06241_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
'�i(1�otkv J- ffK(ish =IATIRI
FROM TO DESCRIPTIO\WellConttractorNam� to fL V 'ilia' tr ate
NC Well Contractor Certification Number 5,.Q 'I`ERX'.AMG forFROM TO DIAMETER THICKNESS
114 serVl�c Gt14Q COI{�f61f�1dYl L� f ft 11 in- sck v Puc
Companv Name .l J 16:'INIVEIt GTiB'STIB
2.Well Construction Permit#•�q 3� WIIuM I Z� 1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ti.e.(�IC.C•ounn.-Stare-Variance.err.) ft. fL to
ft ft is
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural �unicinptal'P ublic ft fL 1�� itti � Y6 �/C
Geothermal(HeatingtCooling Supply) esideial Water Supply(single) fL ft. in,
Industrial/Commercial Residential Water Supply(shared) - —Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fL 10 fL Ili ONrrd
Monitoring ©Recovery' D- ft.
Injection Well: ft. fL
Aquifer Recharge DGroundwater Remediation
19.SAMIGRAVEI:PA£K
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENTMETHOD
Aquifer Test 13Stormwater Drainage 0 ft. 'S fL �
d
Experimental Technology Subsidence Control ft. fL
Geothermal(Closed Loop) Tracer 26i.DRILLiffiG1Iflt" _.
Geothermal(Heating/Cooling Return) r3Other(explain under=21 Remarks) FROM TO DESCRIPTION(mlor.lt dnex,wiVroek ris,etrO
0 R05 browft4
4.Date Well(s)Completed: Well ID# Jt5 ft ft
ft fL
Sa.Well Location:
l RA Meack li4er fL nIN
v" Facility/Owner Name Facility lD-(ifapplicable) ft-
9oZ Floe( Cr , C•rolll 21gz-T ft. ft.
Physical Address,City.and Zip ft. ft.
County Parcel Identification No.(PiN) into pysadoll
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one laviong is sufficient) 22.Certification:1
3t►' 2-1 ;o„ N 1 S"5-1 qq a W !0 0
6.Is(are)the well(s)CIPetmanent or OTemporary Signature ofCcrtifiedri Contra or Date' /
By signing this form,1 hereby ren(ft that the ivell(s)isw(were)constructed in accordance
7.Is this a repair to an existing well: Yes or JNo with 15A A'C.AC 02C AIOo or 15A.VCAC.02C.0200 tyell Construction Standards and that a
If this is a repair,fill out Mown well construction information and explain the nature of the ropy of this record has been provided to the well owner.
repair under 421 remarks section or on the hack 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 13 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
ibr multiple wells list all depths i(dijferent(example-3@200-and 2@100') construction to the following:
10.Static water level below top of casing: L (ft.) Division of Water Resources,Information Processing Unit,
Ijwater level is above rasing,use- - 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Iniection Wells: in addition to sending the form to the address in 24a
12.Well construction method:
above,also submit one copy of this form within 30 days of completion of well
Aw6�(i.e.auger-rotary.cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ,` 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Ig ' Method of test: &bS PWwp 24c.For Water Supply&Injection Wells: In addition to sending the form to
�r_!1rr M the address(es) above, also submit one copy of this form within 30 days of
E
13b.Disinfection type: no Amount: t•S 02. 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