GW1-2021-07461_Well Construction - GW1_20211006

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WELL CONSTRUCTION RECORD(GW-
: 1 "�P' For Internal Use Only:
1.Well Contractor Information:
I�
I—(il ndUn 1'VATER S
Well Contractor Name FROM TO DESCRIPTION
j _1q)'� (�C� tree::a� fL )3S It la �h
NC Well Contractor Certification Number nJ O��Cie 15.OUTEIF:CAS1Nd,:fdt fiiiltl cased wells
rat ft. rL
ItIVII
If/ (,� L(f / I(t/ 'FROM TO DIAMETER THICKNESS I MATERIAL
Company Name ft r_W G in., fi 4(�1^�LJ
I&JNNEX'-ASING:OR;TUBING eotV'eriiialcl as ed=too ,
2.Well Construction Permit#: G W — ���/ / ��C G FROM I To I DIAMETER THICKNESS I MATERLU
List all applicable ivell construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in•
3.Well Use(check well use): ft fL in.
Water Supply Well: i7:SC[tEI?N ,
FROM I TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipaUPublic 0 fL ft. in
FNon-Water
al(Heating/Cooling Supply) 2fesidential Water Supply(single) In-
l/Commercial Residential Water Supply(shared) 1$i GRt7t1T
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Supply Well: 0 It. ofL ( wng RecoveryV"ell:
t'L fL
echarge oGroundwater Remediation
Aquifer Storage and Recovery 19+SAND/GRAYBL':1'ACK,
A Ita'"]icabit:
q g ry Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. fL
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 2b:D1tIIsL•iNG.GOG'.:attach'iitlilid5nalsttee'Y5 if riecess
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks FROM To DESCRIPTION(color,hardness,soillrock .. rain sim etc)
ft ft. D/ /
4.Date Well(s)Completed: '/V_�` Well ID# v fL fL G a C
5a.Well Location: S fL ft 2/AA
�L�►r` jN���Hoc-S ft. �-
FacciiliittvlOwner jN�ame /- Facility ID#(if applicable) ft. iL
/f1t I FUeNez(-r G/l✓fCA �lI A p27 b)Z R. fL
Physical Address,City,and Zip ft. ft
��� d�13:RE1VIAI2HS + '
County Parcel IdentiLcationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well fielK one latflong is sufficient) t `, 22.Certificati1 ( ��N 7 .7`1�"1 W i� L
6.Is(are)the weil(s) Permanent or �Tempotary re of rtitie��_]l�n or Date
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: E]Yes or RNo 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.
i epair tinder#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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: t< S SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: " —(ft-) '
t For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all deeds ijdifferat(example-3Q200'and 1Q100') construction to the following: '
10.Static water level below top of casing: Z Q (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"i. 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: v (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
k(�(12.Well construction method: 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:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) o Method of test: V V 24c.For Water Supply&Infection Wells: '.In addition to sending the form to
f the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: I L completion of well construction to the county' health department of the county
where constructed.
urces Revised 2-22-2016
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Reso
i