GW1-2021-07181_Well Construction - GW1_20211006

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WELL CONSTRUCTION R JRD (GW-1) For Intemal Use
1.Well Contractor Information:
e6 2 14.WATER ZONES '
Well Contractor Name FROM TO DESCRIPTION
u 6 Oft ft. C t�lt r
ft. ft.
NC Well Contactor Certification Number
1S.UUTERCAS1Nti forinolti-cased'wellsR OR'iL1NER'ff"a""""Ilcabte....
h'ROPI '10 _ IIIAMh;1'E THICKNESS M.4'rh:HIAL -
ft in.
Company Name
7 q 16ANNERCA$INC0R,TltB1NC':cOthcrma[ctoscd-hii
2.Well Construction Permit#• �3 D 3 Z�a �L FROM TO DUMETER THICKNESS VL4TERIAL
Lis(all applicable it-ell construction pernrils(i.e.UiC.Courant State.Variance.ea:.) D ft. / to ft. 6-Zyl in- SDR oa i.
3.Well Use(check well use): 9 rt. l ZS✓ i"' -/�� ST ee l
Water Supply Well: 17,SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. ih•
Geothermal(Heating/Coofing Supply) [K'esidential Water Supply(single) ft. ft in,
industrial/Commercial OResidential Water Supply(shared)
t8.�GROUT,.
'Irrigation FROM TO MATF.RIAI. KMPLACEMENT METHOD&AaIOUNT
Non-Water Supply Well: ft tt. fX pe'
Monitoring ORecovery 3 H.
- Injection We1L•_ _
ft. fr.
r1lAquifer Recharge Groundwater Remediation
19.'SANDIGRAVELPACK 0179 iiciihle) 11
Aquifer Storage and Recovery nSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
S
Aquifer Test E)StornwaterDrainage ft. ft.
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) OTracer 20:DRILLTNC L(1G attach additional sheets fnecessa::`:
(color,hardness,soil/rock p e. in size,ctc.
Geothermal(Heating/Cooling Return)
TO DESCRIPTION
) !Other(explain under#21 Remarks) D ft ft. (j,rq ve I/
-°2/-�l Well iD# ft. ! A' fx gve
4.Date Well(s)Completed: •—
ft. t't. ��'
5a.Well Location: .� '
Wr'lltklk Seoe, 11y'le rt. ft. % -
Fucility/Owner Name Facility ID#(if applicable) ft. ft.
2 2 V 6 0l1 Tallu tali & Ile '76) V
Physical Address,City,and Zip ft. ft. } �BC�50
pQ„
�rCC�lc' 21,REMARKS:'.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long its sufficient) p g 3s �/ 22.Certifications�// / /N 03 a , X5� W F7,Z -<
6.Is(are)the well(s) rmanent or ElTemporary Signature(dvCertified Well Contractor Date
P��l By signing this)nrm,1 herehp cer•tih,that the wells)[ear(were)constructed in accordance
L:
7.Is this a repair to an existing well: :f Yes or OK. trirl, 15.4 NGAC 02C.0100 or 15A MAC 02C.0200 Well Construction Standards and that a
If this•is a repair.ill 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 farm.
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: �1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: °L (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nudtiple teens list all depths if diJfereru(ernwplc-J(a�200'and 2(a,1p0') construction to the following:
7 j
10.Static water level below top of casing: 3 (ft.) Division of Water Resources.information Processing Unit,
If rater level is above casing,use'•+" 1617 Mail Service,Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Infection Wells: in addditiun to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 4t r construction to the following: I
(i.e.auger,rotary,cable,titres[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) JLY Method of test: 24c.For Water Supply&Inlet:tion 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: T Amount: �c Cur& completion of well construction ito,the county health department of the county
where constructed.
Fomi G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016