GW1-2021-07447_Well Construction - GW1_20211006

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WELL CONSTRUCTION RECORD(GW-: R*a, For Internal Use Only:
1.Well COn for Information:
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Well Contractor Name _ OM TO DESCRIPTION
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NC Well Contractor caflon N h \ CJ t
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Wl` \�,� p FROM TO DIAMETER THICKNESS MATERIAL
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Company Name
„I6,',RMR')CASING.0I rTUBING therriial'cla erl=)oo
2.Well Construction Permit#: FROM TO DIAMETER i THICKNESS MATEERIIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) C) ft- 5.00 fL 'r y �' Zo•Pr 1, POPE
3.Well Use(check well use): 0 fL 340 ft.
1 I y i", Zw Psi 1 140 pe
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Water Supply Well: "a17:SCREEN ^ ui' a,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public 0 fL ft.
:]Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft
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_ Industrial/Commercial Residential Water Supply(shared) -
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft- ,S�j ft ,i'Y I
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Monitoring I Recovery 0 ft. 3 ft I
Injection Well:
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Aquifer Recharge Groundwater Remediation
__ SttIi;SAND/GRAVEI'.PACK''ifi 'livable;: '; `
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer 20.tDRE LING'L-OG itt9cli•,'addi4obalsfieeYs'ifn"
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks FROM To DFscRlrrloN color,hardness,soiurock rein:ice ur 1
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4.Date Well(s)Completed:S Well ID# 2 20 rL
5a.Well Lo,Cation: R S� D
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Facility/Owner Name V
T n Facility ID#(if applicable)
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Physical Address,City,and Zip ft fL
�d ,2t:REMARKS A'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
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6.Is(are)the well(s)wPermanent or 13Temporary Signature of Certified-Well Contrac or D to
By signing this form,I hereby certify that the'well(s)was(were)constructed in accordance
7.Is this a repair to an eidsting well: Oyes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.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(iW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: L.+ SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifili ferent(example-3@200'and 2Q100) 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: (in.) 24b.For Iniection Wells: In addition t1b 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: !11/ ra Lr-
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
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Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test: 24c.For Water Supply&Iniection Wells: In addition to Sending the form to
the address(es) above, also submit and copy of this form within 30 days of
13b.Disinfection type: Amount: 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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