GW1-2021-07450_Well Construction - GW1_20211006

g�Priflt�o�m
WELL CONSTRUCTION RECORD(GW-1) ' For Internal Use Only:
1.Well Con c r Inform tton r I 711 g
Well Contractor Name FROM TO ft� DESCRIPTION l o ,M
ft ft
NC Well Contractor Certification Number C\ Erp
�/ / �f `�•�PG •�O� 15 OITCI R:G"A,SIN(4:..fdYsdiilli-cased.ivells';ORiti MIR if ii iblli•Litle .
FROM TO DIAMETER I THICKNESS MATERIAL
&2 ft Y In.Company Name J�(• �, 0
/� ��` -�;16:$NIVER'CASINGOR,TUBING CwtH�riiiale)aseil=ldo `-�.
2.Well Construction Permit Il: t-/� ^ FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL ft in.
3.Well Use(check well use): ft ft in.
;17.:SCRERN c.Water Supply Well: .. ., ,:r •. �.:. -- ..
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0Agricultural QMunicipal/Public 0 ft rt fn.
Geothennal(Heating/Cooling Supply) residential Water Supply(single) ft ft
Industrial/Commercial Residential Water Supply(shared) J)i,GROUT.
1irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 7'V ft
rExperimental
Recovery ft ft.
ell:
Recharge e []Groundwater ft. fL
g �GroundwaterRemediation
,WSAND/GRAYEL`PACK;if a"'licable _
rage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
st OStormwater Drainage rL ft
tal Technology Subsidence Control ft. rL
Geothermal(Closed Loop) Tracer .,DAWLllVGIQG;iittach8dditibnal sheett;dn�ceas'"
Geothermal(Heating/Cooling Return) Other(explain under 921 Remarks FROM1 TO DESCRIPTION(color,hardness,soll/rock tym K. ram sim,eta)
0 ft. f rL �/ G
4.Date Well(s)Completed:�2�/; Well IDff
&n.Well Location: S rL
ft. rL
Facility/Owner Name l Faciityd�DDJ(ifapplicable) ft ft.
4��5 del Tj �•t bit.711J�d!r ft. ft
Physic/all Address,
City,WZip t ft. f
7r651 21'REI4IARKS / ;'.
Counq Parcel Identification No.(PIN) CffiN �i7
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one llat/lonng(is sufficient) Q 2 22.Certification:
35 —�V �SSJS� W
6.Is(are)the well(s) ermanent or OTemporary Signature of Certified Well ContractorIfite f
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes orffNo 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:
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (fL)
24a. For All Wells: Submit this form within 30 days of completion of well
Tor multiplewells list all depths if different(example-3@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 water level is above casing,use"Y 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) I.
24b.For Iniection Wells: In addition to sending the form to the address in 24a
L
12.Well construction method: �J
above,also submit one copy of this form within 30 days of completion of well
Q�� / ll f h ti trucon to the following:
(i.e.auger,rotary,cable,direct push,etc.) cons r
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
!13a.Yield(gpm) `3C7 Method of test: D W 24c.For Water Supply&Iniection Well: In addition to sending the form to
t WRY
address(es) above, also submit one 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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