GW1-2021-07760_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
1411916
Well Contractor Name FROM TO DESCRIPTION
6 ,tq ft. 6!�z If.
--T,0-t- 6�r
NC Well Contractor Certification Number �AS.-OUTER CASING for. nItI-cased OR LINER'TM=R If hpolleable)
FROM TO DLAMET El I MATERIAL
Ulfft.Company-Name/
-16.-INNER CASING ORTUBING,(ge6thitiiud!cl6s6d=toop)
2.Well Construction Permit#: 13 o 2 61 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(.e.UIC,County,State,Variance,etc.) M ft. an.
3.Well Use(check well use): ft. ft.
Water Supply Well: :J7.SCREEN-`,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:)Agricultural OMunicipal/Public fL ft. in.
JGcothermal(Heating/Cooling Supply) ORes' ential Water Supply(single) ft. ft. in.
-]IndustriaVCommercial 132tidential Water Supply(shared)7)Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. AU ft. Pz,,,,-77
D!Monitoring ORccovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge [)Groundwater Remediation
Aquifer Storage and Recovery OSalinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
z Experimental Technology [3Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer -20;DRILLING-LAG`affach additional sheets iftece-s-sary),
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilfrock type,gnin Si7A etc.)
4/0� I'. 6e-el
4.Date Well(s)Completed: oZ Well ID# e-10 ft' p0 ft' V
5a.Well Location: fL ft.
I— ft. ft.
/ //-1? JWg-5 r
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft. ft.
Physical Address,City,and ZIP ft. ft. J
-"y 21-REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
0
N W --2L
6.h(are)the well(s)eKrmanent or E3Temporary Signature of Certified 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: DYes or EK. 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#21 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 I GW-I 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: qzv
—00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifiliffvwif(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (fL) Division of Water Resources,Information Processing Unit,
Y water level is above casing,use 1617 Mail Service!Center,Raleigh,NC 27699-1617
11.Borehole diameter:-11,11 AY (in.) 24b.For Injection 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: 4'r %/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
13..Yield(gpm) Method of test. Z,= f 24c.For Water Supiply&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: 7-e4j- Amount: �4Oe-7 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