GW1-2021-07444_Well Construction - GW1_20211006

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WELL CONSTRUCTION RECORD(0*S?� For Internal Use Only:
1.Well Contractor Information: t -
Well Contractor Name ^ FROM ft. fL
TO y�DESCREMONc
1. jy !]SO rt\��
1'1.a \ A �J�� �`� y fL rL
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NC Well Contractor Certification n Number � \'
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ccc��� ea d.Wellb'(SR`TyllH R.if a livable
W > J FROM TO DIAMETER THICKNESS MATERIAL
1 V d7 111 4 It. 9 0 fL t in..
Company Name �i .N V'
�.V�� C�' ;;1br llVN)R CASING;OR'TUHINC etNli rmal,daSEit=too
2.Well Construction Permit#: .J FROM TO I DIAMETER TmCKNESS ,eI MATERIAL• `
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) It. It. in
3.Well Use(check well use): fL It. in.
Water Supply Well: -
FROM TO � DIAMETER SLOT SIZE ' THICKNESS MATERLIL
(' .Agricultural Municipal/Public iL n in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft in
Industrial/Commercial Residential Water Supply(shared)Ni&GROUT ,r
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
Monitoring 'Recovery ft. fL
Injection Well:
It. ft
Aquifer Recharge QGroundwater Remediation
;`a9;SANb/GRAY,E1`:PAGS;1fa' livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E]StormwaterDrainage ft ft
Experimental Technology OSubsidence Control ft. fL
Geothermal(Closed Loop) [O- Tracer 20rbRII Ii1NG 1 OG attach.8ddltibnalakeets3faeeissu ;> .
Geothermal(Heating/Cooling Retum) 0Other(explain under#21 Remarks FROM To DESCRIPTION color,na,aa sotUrock type,prain sin eta)
_` rr ft. fL '
4.Date Well(s)Completed: ��e Well ID# ft• ft- j.
5a.Well Location: fL ft
\ fL ft
" d
Facility/-Owner NatnO Facility ID#(if applicable) ft- f4
Physical Address,City,and Zip ft ft
21<REMARS8, ,•r
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: m . 0 1 t."e r
(if well field,one llat/long is sufficient) -7 22.Certification:
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6.Is(are)the well(s) Permaneut or E]Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the'well(s)was(were)constructed in accordance
7.Is this a repair to an e7dsting well: 09Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 lVell 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:
S.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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: i
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: i y (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00) construction to the following:
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10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If ivaler level is above casing,use"+`"(' 1617 Mail Service Center;Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition 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: �o rAs`� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
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Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: j7 1636 Mail Service Center,YRaleigh,NC 27699-1636
13a.Yield(gpm) Method of test: t� `�'4�✓ 24c.For Water Supply&Iniection Wells: In addition to sending the form to
1 r i the address(es) above, also submit onelc6py of this form within 30 days of
13b.Disinfection type: 1 Amount: I 1z' completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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