GW1-2021-07463_Well Construction - GW1_20211006

.. Mint Foam
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
1.Well Contractor Information: . -
G
t9-r�- �n4yin P� n�'11 „':14 WAT,EIE ZbNES «
Well Contractor Name FROM To I DESCRIPTION
tL rt ,ryl
NC Well Contractor Certification Number �ti3n p� 0 �;0� o?lo Oc 35 a P'
//fit t t15 0t7T.ER:CAS1NGi:: ,inllltl-cOserl Ne7Lti
i)li w 1 Awle / i../! CO--/J.�f1\� �Q�1y� FROM TO DIAMETER THICKNESS MATERIAL
Company Name w la/C.�.L ll�Cit +� ft ('? ft tn.
;1dt NER'GASING,I)R.
s TUBIlVG: ebtherlhl eloetd loo
2.Well Construction Permit#: (2 D o2 ( —O D ! FROM TO DIAMETER THICKNESS MATERIAL
Lit all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) it. it. ini
3.Well Use(check well use): ft. ft in:
17t$GIfELN.
Water Supply Well:
FROM TO DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
Agricultural QMunicipaUPublic 0 ft n, in.
Geothermal(Heating/Cooling Supply) r esidential Water Supply(single) n, g in.
Industrial/Commercial DResidential Water Supply(shared) air GROUT•: -
Irrigation FROM TO MATERIAL i EMPLACEMENT METHOD&AMOUNT
Noll-Water Supply Well: ft. 2 O fL V
O O
Monitoring DRecovery ft. M
Injection Well: ft [t
Aquifer Recharge QGroundwater Remediation :,19;;SAND/GRAYEL`,PACK:ift'i` livable
Aquifer Storage and Recovery EJ Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
quiferTest oStormwater Drainage fL ft.
Experimental Technology OSubsidence Control H. ft
Geothermal(Closed Loop) OTracer b:Dltlt Ii1NG t OG'.:attaati'iiddtlianalsRi etsaf heeess ";
Geothermal(Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION(color,hardness willmlk rain size,etc.)
o 2 fL "_0
4.Date Well(s)Completed: Well ID# a ft 17. '5 jl�✓
5a.Well Location: tt Q ". /cif r�1 j L
>Am;g D?i^,%s n. It.
Facility/Owner Name Facility ID#(if applicable) it. ft
dc,,Ve✓ n. ft
Physical Address,City,and Zip NC 02 r Q 7 ft. ft
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
z75�7g N l011 `� W ��- Sao-z �
6.Is(are)the well(s) ermanent or Temporary Signature of Certified Well Contractor Date
Dv signing this form,I hereby certify that the ivell(s)ivas(were)constructed in accordance
7.Is this a repair to an existing well: QYes or [yNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
!(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:
You may use the back of this page to provide additional well site details or well
i;.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: t SUBMITTAL INSTRUCTIONS
a.Total well depth below land surface: - OS (N 24a. For All Wells: Submit this form within 30 days of completion of well
For ntultiple wells list all depths ifdifferew(example-3 a 00'and 2Q100) construction to the following:
10.Static water level below top of casing: too A) Division of Water Resources;Information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i,
11.Borehole diameter: __(in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: A/t 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: j
i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1
13a.Yield(gpm) i
Method of test: O `� 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 1(-b 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
I
r