GW1-2021-07453_Well Construction - GW1_20211006

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Info tion:/ ) �'O nO�+ - '71)
Cct(J � /r! /"� @� n 6 {.. ` ATER ZbNES'•T
OM TO " ...
Well Contractor Name DESCRIPTION ! '
� 2(o ft 2(S fL /
ft. j
NC Well Contractor Certification Number
///''��� Q�/1 •'�15';.OIITERGASING::.fotmtlltl4ased wells'iOR.LINER'lf.a iW ble
/1 J f - ) /J0 le 7 le // ri� i'M // FROM TO DIAMETER THICKNESS MATERIAL
�/ V t/ r V W o V<•• /' I6;NNER.0 OING,01RU;UB DIAMETER f W�
ft —7 ft m
Company Name
,, riiel tlased-loir
2.Well Construction Permit#: (�tJ— C/J` 7� 'Z j THICKNESS MATERIAL,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fl ft. in
3.Well Use(check well use): R fL in.
'
Water Supply Well: ^'37.SCREEN:
FROM TO I DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural 0 rcrpaVPublic 0 ft ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 1&GROII`ll ,
Irri atioR FROM TO MATERIAL EMPLAUKENT METHOD&AMOUNT
Non-Water Supply Well: ft. ' ft. L! 4/
Monitoring ORecovery ft ft
Injection Well:
ft ft
Aquifer Recharge QGroundwater Remediation
19i. AND/GRAVt-TAC$ if iIi licablb
HAqUifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage ft ft
Experimental Technology OSubsidence Control ft. ft
Geothermal(Closed Loop) -Tracer '20.1 MMAW I1NG L-0G',.attskh'siddittorielSheets tf necess�
Geothermal(Heating/Cooling Return) 0Other(explain under 421 Remarks FROM To DESCRIPTION(color naraa soik rein stm,etc
ft ft `�©vroe
4.Date Well(s)Completed: S`a 6`Z Well ID# tt tt t!eIre",Y
5a.Well Location: ti O $ 'L
FuAd ra-✓^ 8ul'I'c(rs- ft. ft
Facility/Owner Name Facility I!D#(if appli ble p ft. ft
S ( tS 0P ��� 64kea'I f. fL
Physical Address,City,and Zip �— fL fL
-
Cotinty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certitica
35,9 00-3 N __ 7&,JQ0-7� W
6.Is(are)the well(s)uf"anent or Temporary atureofCe I ell Contractor Date
By signing this form,I hereby cert�that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or io with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
l/`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 oiwter.
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 GW-1(js 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: S (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@100) construction to the following:
10.Static water level below top of casing: Z d aw Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+G 1617 Mail Service Center,%Raleigh,NC 27699-1617
.1.1.Borehole diameter:
24b.For Iniection Wells: III addition to sending the form to the address in 24a
12.Well construction method:
above,also submit one copy of this form within 30 days of completion of well
Y(i.e.auger,rotary,cable,direct push,etc.) construction to the following: jl
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,tRaleigh,NC 27699-1636
13a.Yield(gpm) '� / Method of test: �U W 24c.For Water Supply&Injection Wells: In addition to sending the form to
_ the address(es) above, also submit onelcopy of this form within 30 days of
13b.Disinfection type: FfT1 Amount: IL completion of well construction to the county health department of the county
where constructed.
Fomr GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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