GW1-2021-07483_Well Construction - GW1_20211116

-'•-V .11 c.1"y 1 111'
WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only: C
1.W Contractor Information-
Lll ' �S 1 n a `,14:WATEXZONES
Well Con ctor Name FROM I TO DESCRIPTION
413475-Q ► ft. av fft. L
NC Well Contractor Certification Number I :15:0171 ER CASING To '&r,mniti cased wells OR-LINEROR-LINERifs licablc
v�a 1//5 _11 r Ll 1 n G FROM fL q DIAMETER THICIQVESS MATERIAL
Company game d /� ft. �7 in.
!j q :16;INNER CASING'OR TURING; iothermal closed-loo'
2.Well Construction Permit#: J O FROM TO I DIAMETER I TMaKNESS MATERIAL'
List all applicable well construction permits(i.e.UIC,County,State,YmiancA etc.) ft it. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 7.SCREEN -
FROM TO _ DIAMETER SLOT SIZE TMCKNESS y MATERIAL
i:Agricultural b[]Mu
' ipal/Public ft. it. In.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fL ft. it
Industrial/Commercial Residential Water Supply(shared) I8:_GROUT
Irrl aYIOD FROM TO MA EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft to �ft. t
S Monitoring Recovery ft. g
Injection Well:
Aquifer Recharge oGroundwater Remediation ft. tt.
19'SAND/GRAVEL PACK if a livable
Aquifer Storage and Recovery Salinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. I ft.
Experimental Technology 0Subsidence Control ft. I ft.
Geothermal(Closed Loop) [ITracer 20.DRILLING LOG attach additi6nal sheets if aeeeasa
Geothermal(HeatinglCooling Return !Other(explain under#21 Remarks FROM TO DESCROTION color,hardness,soiltrock in size,etc.
�-
4.Date Well(s)Completed: 3 ag tea! Well ID a � Did! l sc Ro�i# � it. ft
5a.Well Location: ss^' t 5f it• !a(j ft. e o ICE rJ /0
JO1-61 w—Arol;rla ronKe D
Facility/Owner N�lame r Ale-
Physical Facility
r/I #(if applicable) It. ft.
End ttPL{t,LB Ln /ea r Jve-
Physical Address,City,and Zip / ft. ft. N O 1 V/ 16
C
f9 �v7aC 21.-REMARKS _ U
County Parcel Identification No.(PIN) DWR Sil 110N
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t?'rORMATION PROCESS
ING UNI
(if well field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s) ermanent or Temporary signature f ed Well Contractor Date
By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or ONo 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#11 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 is needed. Indicate TOTAL NUMBER of wells construction details. You may alsojattach additional pages if necessary.
drilled:
^,� SUBMITTAL INSTRUCTIONS
�
9.Total well depth below land surface: 00 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdlfferent(example-3@200'and 2&00� construction to the following:
i
10.Static water level below top of casing: 7LJ (ft) 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: & y (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Air Rn-6 y 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) / 5 Method of test: !!1 t^ 24c.For Water Supply&Iniection 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: 7• OZ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016
k