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GW1-2021-07838_Well Construction - GW1_20211102
WELL CONSTRUCTION RECORD(GW-1) For lntemal Use Only: 1.Well Contractor Information: �e llo� .�Acahs 14 WATER ZONES FROM TO DESCRIP PION Well Contractor Name ft. .0 ft a a �S & a o & NC Well Contractor Certification Number I3.:OUTERCASING!:ter initi=esved veellii•©RH�B1tC We l l COit. TPa� MATFdtIAI FROM TO DIAINL7'6dt / G�j @ a fk is / d O V'0 Company Name &MNER CASING OB-T4JBING; tTta�at : 2.Well Construction Permit#: FROM R To DIAMLTFAt THICP7IESS MATERIAL List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. in. ft. ft. 3.Well Use(check well use): Water Supply Well: FROM TO DLOWIdt SLOT SIZE THICKNINS MATFdUAL gr.cultural 13MunicipaMblic 0 & ft in. Geothermal(Heatffq/Cooling Supply) esidential Water Supply(single) ft ft in. Industrial/Commercial Residential Water Supply(shared) aE -ROUT Irri •on FROM TO MATERLAL r Rl!>pLACIIYffiVP ._ OD&AMOUNT Non-Water Supply Well: 6 fa do R' A01e to wt t gf Monitoring Recovery ft. ft Iajection Well: ,t Aquifer Recharge Groundwater Remediation ci9;SitiNDLGRAVEL PACK04604614 Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL. EMM ACEMUff METHOD Aquifer Test []Stormwater Drainage fL ft. Experimental Technology Subsidence Control & Geothermal(Closed Loop) Tracer 20.:DRILLING LOG attach additiomilsheets if Geothermal satin Cooling Return Other(explain under 1121 Remarks) FROM TO DFSCRIPTION eotoq hsrfto%soilfreek dM eo d ft. 3 n. G s6't 4.Date Well(s)Completed:l6—_3 L Well ID# 3 5a.Well Location: fL R 100 CI6N rejk.,V,( ra ft 30c- & 2B71 Facility/ r Name Facility ID#(if applicable) Fe f4 ft ft. Physical Address,City,and Zip h- fL .' �n et h J�i V I 2L12EMARKS , ... County Parcel Identification No.(PIN) e e erN Dr t V-e S, '-4- 5b.Latitude and longitude in degrees/minutestseconds or decimal degrees: (ifwell field,one IwAong is sufficient) 22.Certification N w C O-if /� g 1 6.h(are)the wells) Permanent or Temporary Signature ofCertified ll Conn�ctor� Date By signing this form,I hereby veri#y that the well(s)was(were)constructed in accordance 7.Is this a repair to an existing well: ®Yes or 13,io with 15A NCAC 02C.0100 or ISA 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 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: G� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well For multiple wells list aft depths if different(example.3@200'and 2@100') construction to the following: 10.Static water level below top of casing: D (it) Division of Water Resource's,Information Processing Unit, lfwater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: I(in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a 12.Well construction method: GT���� 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: nn JJ e 1636 Mail Service Center,Raleigh,NC 27699-1636 13s.Yield(gpm) J' Method of test: /3l 6 tA/ 24c.For Water Supply&Injection 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: completion of well construction to the county health department of the county where constructed. Form GW-1 North Carolina Deparhnent of Environmental Quality-Division of Water Resources Revised 2-22-2016