GW1-2021-07323_Well Construction - GW1_20211006

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WELL CONSTRUCTION RE RD (GW-1) For Internal Use C,_
1.Well Contractor Information:
WATER ZONES
T FROM TO DESCRIPTION
Well Contractor Name
,1 �� . 16
O
,n q)S ft. ft.
NC Well Contractor Certification Number
t5.'UUTtLR CASING forin¢tti cased';tvells ORLiNER (f a iical)le
It IfC! �� (1�)"��^ FROM fL t0 ft, DI4MN'I'N;n to THICKNESS MATERIAL
Company Name j/` Y 0
t4,,INNERCA9IN <J1R-Tr RINCticiii1lic,rmalclo§ed=loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG.Counrv.State.tiariance,etc.) ft. f[, in.
3.Well Use(check well use): it. ft. in.
Water Supply Well: �17.SCRfiFN .. s:
FROBt TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public R. Ct. in.
Geothermal(Heating/Cooling Supply) esidenfial Water Supply(single) fL ft. in,
_ industrial/Commercial Residential Water Supply(shared) tg rGROUT
_
irr'I ation FROM To MATERIAL EMPLACRMENTNIF.THOD&AMOUNT
Non-Water Supply Well:
Monitoring DRecovery ft. �� ft. 1d� /7
Injection Well:
Ct: --- fr. I
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a 7ictilik11
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test OStom)waterDrainage ft. fr.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sHeets SCiecessa
FROM TO DESCRIPTION color,hardness,sorUrock e, in size,etc.
Geothermal(Heating/Cooling Retuni) Other(explain under#21 Remarks) fL ft.
4.Date Well(s)Completed:s`�u' � Well iD#
ft. ft.
ft.
S/na�.Well Location: VlJ
Facility/Owner Name
,, Facility ID#(ifapplicable) ft. ft. r;
Physical Address,City,and Zip
2LREMARKS . 1'
�SI.t)!l 1 fl
County Pareel Identification No.(PiN) '•' l�
lil
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladlong is sufficient) C� ( � Q 22.Certification'
�
Ob,MIS N 0 SO S U a (405 W n
6.Is(are)the well(s) ermanent or OTemporary ignature o .edified Well Contractor. Date a/
Br signing this loan,/herehi,cci-66,that the wc110)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or eNNo with 15.4 NC;AC 02C.0100 or 15A;VE'AC 02C.(12U0 Nell Construction Srarulards and that a
!(this is a repair fill out knowt well construction information and explain the nature ofthe copy oJrhis record has been provided?o the well owner.
repair under#21 1entarkv section or on the back of this(nni.
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: �a SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:I p (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths#'dijjerent(example-3(a�200'and_?(,3100') construction to the following:
10.Static water level below top of casing: (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: Lk (in.) 24b. For Infection Wells: In addition to sending the-form to the address in 24a
r.r4_,. i-9! above, also submit one copy ofthis form within 30 days of completion of well
12.Well construction method: C VW� ! 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
E
f
13a.Yield(gpm) Method of test: a 24c.For Water Supply&Injection 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: AAJO Amount. completion of well construction'to the county health department of the county
where constructed.
Forni G W-1 North Carolina Depattment of Environmental Quality-Division of Water Resources Revised 2-22-2016