GW1-2021-07626_Well Construction - GW1_20210903

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.-WATER ZONES
Well Contractor Name ZurER
TO DESCRIPTION
ft.NC Well Cont[actor Certification Number CASING'ttirmu sed'•wells)`OA LIIVER Ira-ncable
t , FROM TO DIAMETER T111 NESS MATERIAL
Name
ft' / Q ft- in. ^2 1//
Company Name t0 V C._
22 ^ 16.INNER.CASING'OR TUBING .eothermal closed-loon)
,
2.Well Construction Permit#: �^ ©J //�LI �? O PROM TO DIAMETER TInCKNESS MATERIAL
List all applicable well construction permits(i e.UiC,County,State,Variance,etc.) ft. ft. ;n•
3.Well Use(check well use): ft ft. in.
Water Supply Well: %17:SCREEN -
FROM TO I DIAMETINt SLOT SIZE THICKNESS I MATERIAL
Agricultural E3Municipal/public 0 ft• ft• in.
r-Geothermal(Heating/Cooling Supply) 5<1'sidential Water Supply(single)
ft. ft.
Industrial/Commercial DResidential Water Supply(shared) 18'GROUT Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft- ? r —`
t Q1/'Cc1
Monitoring __Recovery ft. ft. .111
Infection Well:
ft. FG
Aquifer Recharge E3Croundwater Remediation
19 SAND/GRAVEL.PACK 'livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage
Experimental Technology Mi Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING-LOG attach additional sheets.if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION color saran sollfrock etc.
D fL "L G/1
4.Date Well(s)Completed: :9 '2 Well W# ft. 2 ft. L��
5a.Well Location:
g ft. �? I.
///J/� �? ft. ?„ ft,
Del✓1 4 j`�C a-��f1 C O _aCJ
Facility/Owner NamelI Facility ID#(if livable) ft. M
) _Ale-, frC ft.
RF <
Physical-Address,City,and Zip ft. ft
1 fir 21.REMARKS:
County Parcel Identification No.(PIN) uO
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: lQ ldl''
(if well field,one fat/long is sufficient) 22.Certificatio . QR;,3o�R
3-. 3 N 79, �72�e-/h
6.Is(are)the well(s) rmanent or Temporary Sign of Certified well a r Date ,
/ By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an exdsting well: E3Yes or �HF with 15A NCAC 02C AI00 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair.fill out)mown 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 addidonal 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: �L (ft•) 24a.For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths if different(example-3©200'and 2@ 100 1 construction to the following:
10.Static water level below top of casing: z t] (tt•) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
1
11.Borehole diameter. �O (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well constriction method: rr
above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) E
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 S �^� Method of best: �t/Ot J 24c.For Water SunDly&Injection Wells: In addition to sending the form to
J / the address(es) above, also submit one copy of this form within 30 days of
•
13b.Disinfection / Amount: D LL c r 6 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