GW1-2021-00396_Well Construction - GW1_20211230

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WELL CONSTRUCTION RE', ID (GW-1) For lntemal Use O
1.Well Contractor Information:
A, ec, Id,RiITEIY:ZAI!1ES s
FROM TO DESCRIPTION
Well Contractor Name JA ft. [ ft.
NC Well Contractor Certification Number 15,UUTERCASING(foe iiioltieAsave7ls UR.L7N6R'if:8 Iicabtei
FROM 10 .1ANI NTI'N;R 'THICKNESS MATERIAL
Ile r 0 ft. �� ft. 5�in.
Company Name
©� tG.1NNER CASING UR;hUBiNC 'cothefmal c:IpsCd-10ti'.
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MAATERIAL
List all applicable well construction permits(i.e.VIC,County,State.Variance.etc,) Q So
r"' sC/1 �l� f�li
3.Well Use(check well use): ft. ft. in,
Water Supply Well: 17.SCREEN.
FRONT TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural DI Muticipal/Public ft. R. in.
Geothermal(Heating/Cooling Supply) Ukesidential Water Supply(single) ft. ft. in.
industrial/Commercial Residential Water Supply(shared)
1$.GROUT ... ... .<....'
Irrigation FROM 'I'O MATERIAL FMPLACKMENTMF.THOD&ANIOUNI'
Nun-Water Supply Well: ft. S tt. /f 0 U/ed
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
I9.SAND/GRAVEL Pi1CK if:a Iicible Aquifer Storage and Recovery Salinity Barrier MOM To MATERIAL j EMPI.ACEN[ENT METHOD
Aquifer Test [3Stomtwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer v20.DRILLINGS OG itfar additiui aLsheets it iecessa. 4 4 sl ,,=:
FRONT TO DESCRIPTION color,hardness,soil/rock type.grain size,etc.
RGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
4.Date Well(s)Completed: -8Z-V Well iD#
5a.Well Location: /f ft. Zoo ft.
Facili y/Owner Name Facility ID#(it applicable) ft. ft.
�-b W,/Aer A"'If flog� ft. ft. ?SECTK1
Physical Address.City,and Zip fl. ft. INF{,MTr))F;�'I ll7F.SSNG In'
21:REMARKS.:':
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifw?ell field,one lat/long is sufficient) 22.Certification:
�J �0 �•�• d�� N O�36 �fS• �7 v1" y` d�'��
6.Is(are)the we0(s) Permanent or Memparary Signature 6fCertified Well Contractor Date
By signing this 1brm,1 herehy cergh-that the well(sl was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or to with 15.4 NCAC 02C.010f)or 15A NC'AC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,ill out known well construction information and explain the nature gjthe copy of This record has been provided to the well owner.
repair rarer#21 rrniark,s section or on the back ofthis orm.
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: SUBNUTTAL INSTRUCTIONS
9.Total well depth below land surface: �o (ft.)
P 24a. For All VYells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdiijferent(erample-3(&,200'cad 2(4,100') construction to the following:
/ I
10.Static water level below top of casing: U (ft.) Division of water Resources,information Processing Unit,
Ifxaler level is above casing,use-+" I 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Iniection 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
12.Well construction method: 4°r construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUP/PLY WELLS ONLY: nn 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1,Z Method of test: �7 4� 24c.For Water Supply&lnjection 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: Ilye- completion of well construction to the county health department of the county
where constructed.
Fomv G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016