GW1-2021-07789_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only.
1.Well Contractor Informa'on:
14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
06 ft. 107 ft FFY i ' rAn,'t,_
NC Well Contractor Certification Number 3 ObTERCASIIVG fo ;mo16P:c- eed.w l-017�f
so R, ft
N/� 'e OR7siNE[t`�s lieable
Do6T i We I I prd I// Mom TO DM WTER MUCKNESS I MATERIAL
CompaayName 4' ft. ft- m. SDA-21 1 P VC
16.INNER CASING•ORTMINGL('eodiermal closed-too , .
2.Well Construction Permit#: FROM TO DIAMETER TMCKNESS MATERIAL
List all applicable well construction permits r.e UIC,County,State,Variance.etc.) ft ft. in.
3.Well Use(cheeltwell use): ft. ft in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)MunicipaMblic ft ft. in.
Geothermal(Heating/Cooling Supply) FRcsident4Water Supply(single) tt ft in.
Iodustrial/Cormnercial DResidential Water Supply(shared)
71firigation. FROM TO MATERIAL EMPLACEMENT METHOD&AMOUxT
Non-Water Supply Well: % Cj
� : Qel'1 TO t' PV t4�
Monitoring Recovery it. ft.
Injection Well: ft, ft
-_Aquifer Recharge Groundwater Remediation
39.SANDIGRAYEL PACK('d'a" illcable
Aquifer Storage and Recovery ©ISalinity Barrier FROM, TO MATERIAL EMPLACEMENT METHOD
•_ Aquifer Test i_. Stormwater Drainage
ft ft.
Experimental Technology EISubsidenceControl ft. ft
Geothermal(Closed Loop) OTracer 20.DRII:I:ING LOG-(attach addidenafsheets if necessary)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM TO DESCRIPTION lcator,hnrdoes9 soNrock rain" etc.!
ft. ?� ft- ,���. sit
a.Date Well(s)completed: '- well 1D# 71
ft. 400 ft f f 'f
Sa.Well Location:
ft ft.
D(ay►'S &AM ft ft. x
Facility/Owner Name Facility rD#(if applicable) Kr,J
end oF- Muion Lewis Rd, We+c-P Kes,�anT vt ft. ft 2
ZA
Physical Addicss,City,and Zip ft ft. l jt1i1
Ash 1 S 27 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/mim ites/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N w 00000,
6.Is(are)the wellwa) ermanent or OTemporary OlKature of Certifieff Well Contractor Date
By signing this form,I heieby certify thacthe xr11(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes orlo with 15A NCAC 02C.0100 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 thisfirm.
23.Site diagram or additions]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: 400 (ft) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample-3Q200'and 2©1001 construction to the following:
10.State water level below top of casing: 10
(fk) Division of Water Resources,Information Processing Unit,
If uvater level is above casing,use" g 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the foam to the address in 24a
1 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:6 ff �1G�(t/ 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
13a.Yield(gpm) y Method of test: f If 24c.For Water Supply&Inlectfon 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: l�[L,!1 Amount: 6-OZ completion of well construction to the county health department of the county
where constructed.
h
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resoumcs Revised 2-22-2016
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