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HomeMy WebLinkAboutGW1-2021-07444_Well Construction - GW1_20211006 • .. ;:�t�fnt Fohm t . 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 r � NC Well Contractor Certification n Number � \' :.1&-'0 T2J1,CA91N6,fdi•hiiilti 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: 0 i� / 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: •1 Q 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.) h 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 i