GW1-2021-04629_Well Construction - GW1_20210510

\ WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well
Contractor Information: 7 ,�
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FROM TO DESCRIPTION
Well Contractor Name
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NC Well Contractor Certification Number t '? nressm
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P/ �-0 1 1 (A)to I l� ft ft• In. I Q 1
Company Name 41VNER=G�1NG�ORn1'UBINGR
Z.Well Construction Permit#• �o TM MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc) ft. it. in.
3.Well Use(check well use): ft. ft.
Water Supply Well:
PROM TO DIAMETER SLOT SUZ+ THICKNESS MATERIAL
❑Agricultural ❑M�unicipal/Public fL fZ in
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. fL �•
❑lndustrial/Commercial ❑Residential Water Supply(shared)
DIrrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT ME OD to AMOUNT
Non-Water Supply Well: Q ft. d IL ecl
❑Monitoring ❑Recovery ft. ft.
Injection Well:
fL fL
❑Aquifer Recharge ❑Groundwater Remediation
?49-:$AND/GRAVELPAGK" e g
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEM]INTMETHOD
❑Aquifer Test OStormwater Drainage ft. it
DExperimental Technology ❑Subsidence Control ft. %
❑Geothermal(Closed Loop) ❑Tracer „20J)RILM- GLOG,attxcti adMboil lhheeta9fn s __
❑Geothermal catin Cooling Return ❑Other(explain under#21 Remadts FROM TO DESCRIPTION color hardness,aolUrae� eta ?
4.Date Well(s)Completed:,��"�`-�-`— Well ID# ft' 6 ft. G G
5&Wen Location: OL 16
IL O R. saln ef
PCtt)evt 140 rh0S ft o % ra�t
Facility/Owner Name Facility ID#(if applicable) fL f
a_01 4 MA d°L fL
Physical Address,City,and Zip ft. ft
W r1.I�'L '21.RRE1VI7iRKS _ _ �� Y.�a,�` �'��«:�-��,� r�`•
County Parcel Identification No.(PIN) Z° Gr .t°h rive s O Q
1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W
6.h(are)the well(s): t7Permanent or ❑Temporary Signature of Certified Well Cafftra&or Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ftNo- 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known Nell construction information and explain the nature ofthe 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 construction info
construction,only 1 GW-1 is needed Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
filled' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Ll
For multiple wells list all depths if different(example-3 00'an7d�2Qa 100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: V ( ) 249. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+f' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
LL Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ❑TA r 24c For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducin over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Pemut Program,1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type:�- Amount: !�]
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-&2018