GW1-2021-07448_Well Construction - GW1_20211006

WELL CONSTRUCTIORD(GW-1) ' For Internal Use Only:
"ON RECORD Ilj
I.Well Contractor Information: t
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'sad.'VV RAT� yb
Well Contractor Name FROM TO DESCRIPTION I
.3 /1-//-14 C 6 ��nwr Idu ft. ft
ft
NC Well Contractor Certification Number
Ot10 .r15"`O't)1'ER�.CASIlVG"foimutti=c6IAMsedw lls ORsT.INER'If.a:..ticLble
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��(•Ss��� e FROM TO DETER THICKNESS MATERIAL Company Name / VVV w� 1 `—S�k�+ ft in. G(I/,,Z C/
1641NNEI CASING Dtf.T TTG eotherma!closed-loo
2.Well Construction Permit f1: !T w'- OS��S�t I FROM TO DGIMEIEA THICKNESS MATERGL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL fL in.
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3.Well Use(check well use): fL ft in.
Water Supply Well: 17.SCRM EN
FROM I TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
Agricultural QMunicipal/Public O 6L . p ( in ,Z Iv� A
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft ft `-l In a l�
Industrial/Commercial DResidential Water Supply(shared) Iti:.GROUT:
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD Non-Water Supply Well: ft. ZU ft 6 �j e LJ r
Monitoring nRecovery ft. IL
Injection Well:
ft.Aquifer Recharge Groundwater Remediation ft
19:}SAND/GRAYEU PACK;(it i'"Iieable
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL —EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage y fL
PDExperimental Technology Subsidence Control n. ft.
Geothermal(Closed Loop) Tracer �20 rDRthL-MG t'OG;attach iddi8oniil'sheetsrtnecess
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks FROMI TO DESCRIPTION color,b+vdnes,sallf k type,grain size,ete)
- ft. N �.
4.Date Well(s)Completed: y Z Well ID#
5a.Well Location: fL S fL
Facility/Owner Name Facility ID#(if applicable) ft. rL
Z Z 3 7 0&y,S *w n 2,1 Ltln A ,e// /t/� 7s,7 fl. ft.
Physical Address,City,and Zip ft. fL
Comity Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one/Iiattlong is sufficient) f i 22.Certificatio '
5.S `-1Co� N — .`1 33p�� W
6.Is(are)the well(s)&rPermanent or OTemporary of Certified Well Contractor Date
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By signing this form,I hereby certify that the wel(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or M Vo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
tf this is a repair,fill out known well construction information and explain the nature of the copy of this retard has been provided to fire 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 GyJ-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 i
O SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: A) 24a. For All Wells: Submit this form within 30 days of completion of well
le-3
For multiple wells list all depths if deren[(examp@200'and 2@100') construction to the following:
10'Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
if wa/er level is above casing,use••+'•/ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:
(1°') 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Y above,also submit one copy of this form within 30 days of completion of well
(i.e,auger,rotary,cable,direct push,etc.)
construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underglund Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test: 3 24c.For Water Supply&Injection Wells: In addition to sending the form to
i the address(es) above, also submit one copy of this form within 30 days of
j 13b.Disinfection type: Amount: I L completion of well construction to the county health department of the county
where constructed.
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-20I6
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