GW1-2021-00313_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Inforrmation:
1�(A(/V W t 1\- t�(� 14.WATER ZONES i.
FROM TO DESCRIPTION
Well Contractors ame
225 63— Iso
ft. Q� ft. Yyk
NC Well Contractor Certification Number 15 OUTER CASING for multi-cused;wells OILI R if a "licable
FROM ft TO DIA/M_ETER `THICKNESS MATERIAL In
Company Name
^ 16.INNER CASING ORTUBING' eother'mal closed-loo
2.Well Construction Permit#: S F,� 4� 1J� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROMREEN O DIAMETER SLOT SIZE THICKNESS MATERIAL,
_!Agricultural E]Municipal/Public ft. ft. fin.
:,),Geothermal(Heating/Cooling Supply) F&esidendal Water Supply(single) ft. ft. in.
--]Industrial/Commercial EIResidential Water Supply(shared) 18:`ROUT.
_! Inri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT"
Non-Water Supply Well: © ft. 3(, ft. deh It i i qrA 17AU/'4
:-)Monitoring Recovery ft. ft. 36 _ Olb baq.5
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
'
Aquifer Storage and Recovery 0ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStonnwater Drainage
Ji Experimental Technology ISubsidence Control
Geothermal(Closed Loop) (Tracer 20.DRILL]NGLOG attach additional sheet`;if nccessa'
BGeothermal(Heating/Cooling Return) (explain eX lain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc)
(Heating/Cooling RetuReturn)) I
© ft. 2 ft. .f S A i'
4.Date Well(s)Completed: Well ID# A ft. 2 ft' a)J cl0.
5a.Well Location: r �i),J l2 rt. ft. utL GI a
�) q u 1 IA 6 l►1 E /�,l d s
Facili /Owner Name Facility ID#(if applicable) 6 Dft. Im(D/ ? ft. -n /�
�_�,,!Main 5tKeei l !<J iki eS - _ '� ft. A0 J ft. Y(/` rOC [
Physical Address,,City,and Zip / r� ft. ft.
14&rnt, 04027—bt-W 1��000 21.REMARKS
County Parcel Identification No.(PIN) tt
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: �OZ
35 0 a5, M N UP q3 , q 74P w n ` gar t l t _,Z 61z o
6.Is(are)the well(s) Permanent or [(Temporary Signature of ified Well Co actor ` " Date 9?d�Q(f";11"r
By signing this form,1 hereby ceriif(that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well• DYes or No with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature ofthe copy ofthis 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-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: 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'aanndd 2@100') construction to the following:
10.Static water level below top of casing: a a (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service'.Center,Raleigh,NC 27699-1617
11.Borehole diameter: ' (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
rn
12.Well construction method: 1'L Ul rotaY� 0\)f ro t i y 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) Method of test: JP(.t1' fel/IC) 24c.For Water Supply&Iniection Wells: In addition to sending the form to
I r 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016