GW1-2021-07557_Well Construction - GW1_20210903

WELL CONSTRUCTION RECORD GW-1 For Internal Use•Only:
1.Well Contractor Information: ``' _
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5� Ga �j _
14.WATER
Well Contractor Name 5 0 fL ft DE V
SCIUM(
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^ J� �j� �Q� O� fa ft. i
NC Well Contractor Certification Number S `l&OUTER.CASING UdiiaWficased.well§ OR'LINER f061ieeble !=i't:;<;:.;; 7
FROM I T S I MALTERIAL
Company Name & ft in. 15 l
1&EVER'CASINGOR:: ING: eoth&i"
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
1 o�a iY
List all applicable ivell construction permits(f e.UIC,County,State arf�c.) & & in.
3.Well Use(check well use): ft. ft
Water Su I Well: 517.SC1tEEN'
FROM I TO DlAMEFER I SLOT SIZE I TRICKINESS I MATERIAL
. Agricultural JDM at/Public O a ft im
Geothermal(Heating/Cooling Supply) esidential'Water Supply(single) R ft is
TndustriatlCommercial Residential Water Supply(shared)
zltiiGROUT:;
tr[i ati0n FROM TO MATERIAL EMP1ACF1dEaMLM0D&AM0UMI'
Non-Water Supply Well: 0fc Za& Jjowl t
Monitoring []Recovery ft ft
Injection Well:
Aquifer Recharge ft it
Groundwater Remediation
:;�19:•SANDIGRAVELPACK iblieble s`:<;;;<ise::
Aquifer Storage and Recovery nSalinity Barrier FROM TO MATERIAL I EMM.ACEt FM MEmoD
AquiferTest Stormwater Drainage n• ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) 13TMcer 20.`DRII:,1NG LOG aftaeh'addiHoual aheets'ifceba36' s:;:. I:ai; „r
, .
Geothermal(FIeating/Cooling Re Other(explain under#21 Remarks) FROM TO tt •© ft DESCRIPTION(colorbmdnesssonhoek minezg
OU &)p,. ov ;
4.Date Well(s)Completed: Well ID# 50 ft ft ,1-q-I f w -
Sa.Well Location: ft 'L�,ft.
fj 2Qa ft O$ft
Fachity OwnerName Facility
1D#(if applicable) ft ft
I7 / 6 / � t�b l I a K i ft ft
Physical Address,City,and Zip ft ft
411RFMARES
County �1 Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaNlong is sufficient) tt
22.Ce ea
Im
6.Is(are)the wells) ermanent or OTemporary Signatnre ofCadfied Wail Contractor Date
By signing this form,I hereby certify that the well(s)was(wen)constructed in accordance
7.Is this a repair to nn existing well: nYes or [3No with ISA NCAC 02C.0100 or ISA NCAC 01C.0200 Well Construction Standards and that a
Ifthis fs a repair,fill out known well construction information and explain the nature of the copy ojthts record has been provided to the reel/owner.
repair under#2I remarks section or on the back ofthls 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 also attach additional pages if necessary.
drilled' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_ (14) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths#'dVierent(example-3@200'and 2 00) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above coslny,we '+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this;form within 30 days of completion of well
• 12.Well construction method: construction to the following:
(Le.auger.rotary.cable,direct push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY LLS ONLY: �j 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield,L(gpm) Method oftest:F Ll /: 24c.For Water Sunnly&infection Wells: In addition to sending the form to
G the addresses) above, also subink one copy of this form within 30 days of
13b.Disinfection type: kil Amount: completion of-well construction to the county health department of the county
where constructed.
Form GW-1 North Cafglina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016
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