GW1-2021-05460_Well Construction - GW1_20210615

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
1.well Contractor Information:
DUSVIA Jek.LJOA ' `14:-,WATERZONES'.
Well ContactorNsme 1 .4 FROM TO DESCREMON
NC Well Contractorcetti5cation Number �tv� k �021 UO R R
U 5._0U1ER CASING"for"m wells OR3�iSB`d
Upfron-k FROM TO DIAMETER 7113OUG S MATTERiAL
„1'1i�—�4e'ti9IL fk it in
Company Name �(i D ;�. / &tINFA Ze
16_INNERCASWG OR`TQBING: ."'theem
2.Well Construction Permit#: FROM To 1 DIAbIEIFdt 7ffiCItNFSS MATERIAL
last all applicable well construction permits(i.e.UIC,County,Stare,Variance.eta) & it. in.
3.Well Use(checkwell use): R & in.
Water Supply Well: 17.;SCREEN
FROM TO
cultural DIAMETER SLOT SITE TMC�S MATERIAL
Agri
Geothermal(Heating/Cco �MunicipallPublic 0 g, & in.
Supply) rOResidential Water Supply(single) n & in
Industrial/Commercial (3Residential Water Supply(shared) 18=GRUUT
Irrigation FROM TO MATERIAL EWI ACEMENT METHOD&AMOUNT
Non-Water Supply Well: it W itILE
1
Monitoring co ri
.9
Revery g, g,
Injection Well:
R Aquifer Recharge Groundwater Remediation R
pp��Salim Barrier 194 SAND/GRAVEUPACK if e■Mc
quifer Storage and Recovery
!.T tY FROM TO MATEMAL` HYIPIr\CEi1>HrTf METHOD '
Aquifer Test - OStormwater Drainage R
Experimental`Teglmology E)SubsidenceControl & &
Geothermal(Closed Loop) Tracer 20.D G LOG stt a addidoW shseia if
Geothermal(Heating/Cooling Return) nOther lain under#21 Remarks FROM1 ToDESCRWTION color,hndams,-Wnr4 ' size,etc
ft it �
4.Date Well(s)Completed:,a well ID# is it
Sa.Well Location: O ft 6 fz 6twLe
Ve Me5 ft. it
Facility/Owner Name Facility IDk(ifapplicable) &. it
(g3 C v fir nlr� i �.s+ ft it.
Physl Address. ity,an Zip it fc
-11.REMARNS " "
County Parcel Identification No.(PiN) a ! I 1 V e'
5L Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W C ZO 2
6.Is(are)the well(s)OPermanent or 13Temporary Signature ofCerti6ed VXWCoffmctor Erate
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: 13Yes or &fNo with 15A NCAC 01C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a
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 thisform.
23.Site diagram or additional well details:
8.For GeoprobeMPT 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 l GW-1 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: 6r
( ) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2@100') construction to the following:
10.Static water level below top of casing; Division of Water Resources,Information ProcessingUai
Ifwater lave!is above casing,use + 1617 Matz Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (fn) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: �r./ above,also submit one copy of this form within 30 days of completion of well
(i a anger,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) Method of test: g D 1.L_ 24c.For Water Sanoly&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: Amount; 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 20I6