GW1-2021-00066_Well Construction - GW1_20211109

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use only:
1.Well Contractor Information:
14.WATER ZONES
WeUContractorName FROM To DESCRIPTION
ql7 ft. fw
,��DJ: 1y it. ft.
NC Well Contractor Certification Number -11.OuTmi Gcmrman' R LIIPiM a 1[cabie
big.L e- 1 t..�s )'M. FROM TO DIAMETI$t THICKNEBB MATERIAL
WWnyName Q. t�. s. in. .2 Pitt,
Company Name 16.INNER CASING OR TUBING
2.WeU Construction Permit : FROM TO DIAMETER I TMCtcNM MATERIAL
List all applicable well construction permits(i e.UIC,Courtly,State,Variance,e1c.) ft• R. in (J
3.Well Use(check well use): t:. ft. in. 7
EAgricultural
ply WeII: 17.SLIMN:FROM TO DiAMBTER SLOT Si?$ THIC�1B33 MATERIAL
[3Municipai/Public p (L it.mal(Heating/Cooling Supply) Geidential Water Supply(sigle) ft, ft. Io,l/Commercial DResidential Water Supply(shared) i&GROUT 1
n FROM TO MATERIAL EMFLACanZ1vr MEMOD ac AMOUW
Non•Water Supply Well: A ft• 70 ft• ^ f
Monitoring _ Recovery 10 fL ft.
Injection Well:
Aquifer Recharge [313roundwater Remediation
.]9::SANDID/GRAVFJ RACK f. limbk
Aquifer Storage and Recovery 13Salinity Barrier FROM TO I MATERU►i I EMPLACEbiLW NUnNOD
Aquifer Test [3Stormmwater Drainage ft. ft.
Experimental Technology 13Subsidence Control fa
Geothermal(Closed Loop) DTraca 20.DRILU NG MG attactr additional sheets if
Geothermal Hearin Coolin Return Other lain under#21.Remauks) PROM To DESCRIPTION color sm'lhoe& eta
ft. it. b�
4.Date Well(s)Completed:zpae-v well M# ft• ft• L
Sa.W Well
lLLocation: ft.
==1-t �'-� ft. ft.
Facility/Owner Name Facility 1D9(if applicable) fL fL
fL ft.
Physical Address.City.and Zip
ft. f.
2L REMARKS
Pv-. u4
County Parcel Identification No.(P1N)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: tt,Mpunnhi PRnMS10[IN!
(if well field,one la long is sufficient) 22.Certification:
S�34N _7��Sr 3�..7.32Z7 & p� -41.041- 10-29
—24
6.Is(are)the well(s)00ermnent or OTemporary Sigitafte of Certified Wepftftwor Date
By signing this form,I hereby certify that the well(s)war(were)constructed in accordance
7.Is this a repair to an existing well: Mes or 0T0 with 15ANCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,f ll out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair utider#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 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details..You may also attach additional pages if necessary.
drilled: SUBM3TAL INSTRUCTIONS
9.Total well depth below land surface: ,J7,D (ft.) M.For An Wells: Submit this j form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'a d 2@1005 tnstuation to the following:
10.Static water level below top of casing: "9_6L UP Division of Water Resources,Information Processing Unit,
If water kyel is above casing,use"+" 1617 Mall Servlcebenter,Raleigh,NC 27699-1617
11.Borehole diameter. (in) 24b.For Iniecdon Wells: In addition to sending the form to the address in 24a
Aar-
also submit one copy of this form within 30 days of completion of well
12.Well construction method:_ Aar-is I _ -_ _ construction to the following:
(Le.auger,rotary,cable,direct push,ere.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
/� 1 ?
13a.Yield(gpm) _Method of test:V 24c.Fr�a��p�1x8c Lmiecofon�eils: In addition to sending the form to
the address(cs) above, also submit one copy of this form within 30 days of
13b.Disinfecdon type: P oru Amount: completion of well construction lto'the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Rasounxs Revised 2-22-2016