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