GW1-2021-07472_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD(GW-1) For internal use Only:
I.Well Co tractor Info tion:
L. '.la WATExzONEs
Well Contractor Name FROMTO I DERIPTION
e3&5"L IL
NC Well Contractor Certification Number 1 /r f/// 15°U1 F1 ER CASING o multi-eased;wells UBI IlNER- a' amble
6��5 � L t�f<{[f��C� FROM TO DIAMETER THIC[�4S MATERIAL
Company Name f t R A/ 'u
L -16i.I1VNSR"CASING.0RXMING_ ' theirmatcioselt
2.Well Construction Permit#:15G�? ` / FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i e.UIC,County,State,variance,etc.) It. R- m.
3.Well Use(check well use): IL IL in.
:17.SCREEN
Water Supply Well: ,.,
FROM TO DIAM>TER SLOTSITE THICKNESS MATERIAL
Agnculturai fE3 unicipal/Public R. IL m,
Geothermal(Heating/Cooling Supply) Oesidential Water Supply(single) in
Industrial/Commercial Residential Water Supply(shared) dg GROUP PlIrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMrowa
Non-Water Supply Well: p fL n tQe�
Monitoring EIRecovery & g
Injection Well:
Aquifer Recharge DGroundwater Remediation fL ft.
19:SAND/GRAVEI:PAG%"ds.7iceble
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT 1►fE-rHOD
Aquifer Test �Stormwater Drainage fL
Experimental Technology Subsidence Control iw nr.
_ Geothermal(Closed Loop) [3Tracer 2&_DRII:LING LOG sttaehadditfoual iheets iinecesss
_ Geothermal Conlin Return Outer lam under#21 Remarks FROM TO DESCRIPTION color,hardn soihnek. etc
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4.Date Well(s)Completed: r '2► Well ID# ��G fL
5a.Well Location: ,Z/� n
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Facility/Owner Name Facility ID#(if applicable) & %
-.1 7s- 4oS�- Tig. '/ IL ft.
Physical Address,City,and Zip n er. NOV 16
?SGIt� 1L REMARKS 7 -
County Parcel Identification No.
U RZyi1JN
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) 22.Certification:
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6.1s(are)the wells) Permanent or OTemporary signature ofCertificd W tractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [)Yes or E2190 with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0100 Weft Construction Standards and that a
Ifthis is a repair,f if out brown well cons ruction information mid explain the nature ofthe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform.
23.3ite 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 of 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: GL U ( ) 24a,For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3()200'cord 2(a)1005 construction to the following
10.Static water level below top of casing: rl�o , (fL) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
%
11.Borehole diameter. (in.) 241b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well constriction method: IY/fr71�'I
A 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,Undergroind Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) led Method of test: .4• L, !'� 24c.For Water SuDDIv&Infection 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: Alt '] (77, completion of well construction tolthe county health department of the county
where constructed
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2 22-2016