GW1-2021-07147_Well Construction - GW1_20211129

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ELL CONSTRUCTION RECORD GW-1 For Internal Use Only:
/1.
Well Contractor Information•
pP er- � t
Well Contractor Name FROM ft. TO DESCRIPTION
ft.
NC Wel Contractor Certification Number U -
1 --� �IS�OUTERcCASTNGF for.;multi=eased�w`�lls'`:OR§DI]!TFiR if�a Ifcalile
,.,V/� ` - yy� 6 Inc, FROM TO DIAMETER THICKNESS MATERIAL
t�`�J� �� • �1�-""rt' i l ' rt �� ft. �I,'Z,f'(n $�ll.l t�VG
Company Nam
- D D D D to 1G�I1!1NER(CASING UR�T.UBIN.'r"Bather",mslrclosed�l`oo
2.Well Construction Permit#• FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL ft. in.
3.Well Use(check well use): ft, ft. fa.
Water Supply Well: *1,14SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. tt. In.
Industrial/Commercial Residential Water Supply(shared)
1ni ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft. tt. �, � r✓ I �� �- o k1 E
Monitoring MRccovery ft. ft.
Injection Well:
ft ft.
Aquifer Recharge Groundwater Remediation 919 SAN IVGRAYED PACK f I'll iOUR
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer �2L-DIULLINQ11 G.attach ad'dla61ial iheeti itneces��'
FROM TO DESCRIPTION color,hardaeu eollfrock rain a etc.
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks 0 g, 0 ft. 'la fi G 6-4.Date Well(s)Completed: /�t Well ID# 17,0 ft. D ,5 tt. +c0l 5. l J Yd C
5a.Well Locati n:
r 1 ft. tt.
/ ft. ft.
Facility/OwnerNtme Facility ID# ifapplicable)
Vnils, �C/44. LIN &/Ars, Lto
Physical Ad Ass,l� City a Zip ft. ft.
ncorn
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iattlong is sufficient) 22.Cer ftcation: t,
6' Q r/ —YI 31NI5© �1IrU
6.Is(are)the well(s)OPermanent or Temporary ign a ofCertifie Ael[Contmactor Date
signing[his fo rn,1 hereby certify that the well(s)was(%vere)constructed in accordance
7.Is this a repair to an existing well: 13Yes or MNo with
13A NCAC 02C.0100 a•15A NCAC 01C.0200 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 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. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: b (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdo'crent(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of easing: ! a (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: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
p above,also submit one copy of Ethis form within 30 days of completion of well
12.Well construction method: Ro t�-r'/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
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: 41y 24c.For Water Supply&Iniection 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: I'k,O Yl tl it Amount: Lu completion of well construction;to the county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016