GW1-2021-00420_Well Construction - GW1_20211206

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATE NES
Well Contractor Name FROM TO D ON A
02 b —� "14-� fL 1, 6 fL t CQ GR
[t. ft.
NC Well Contractor Certification Number '/�\ 15.OUTER CASING formuld-cased,wells _OR LINER a licable
R . ( 1 1, ►�6 1 �t oc FROM TO D TER T�CIQdESS MATERIAL
Company Name \ © ft. g� ft. 4._in. S�(� l o�'C
16.INNER CASING OR TIIBING othermal¢bead-loo
2.Well Construction Permit#• o�o p� 1 0 4 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) It. ft. in.
3.Well Use(check well use): & ft. in.
Water Supply Well: 17."SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural �[3;MunjciC'
al/Public fa ft. in.
Geothermal(Heating/Cooling Supply) ential Water Supply(single) ft. % in.
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMP CEMENT METHOD&AMOUNT
Non-Water Supply Well: C7 ft & f\C
D
Monitoring Recovery ft. it. b
Injection Well:
ft. ft. fl wf e
Aquifer Recharge Groundwater Remediation - -
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control It. ft.
Geothermal(Closed Loop) Tracer 20.`DRILLING-LOG.attach additional sheets if necessary)
Geothermal(Heating/Cooling Coolin Return) Other(explain under#21 Remarks) rFRj0MTo DESCRIPTION cobr hardn soiUrock in s" e<c4.Date Well(s)Completed: . Well ED# a45a.Well Location: `��p ft. f�f�C-e-. a
Facility/Owner Name LID Ca5z), / Facility 1D#(if applicable) ft.
,� ft.
1/ •C� w ft. ft.
Physical Address,City,aA Zip
c(b o- 1 t� q b 1D 11.RErKARKSr
County Parcel Identification No.(PIN)
' r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) // 22.Certification: SJ 3i(,T 10h
35° 33 /330 /I N toa 4- 1 13 5D ! w � i tj�Pcem TIC-ill}'r;77J W i1(* A-
6.Is(are)the well(s) Permanent or Tempo; N�.
ry Signature of Certified Well Contractor Date 1
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair'to an existing well: 13Yes or with 1 SA NCAC 02C.0100 or 15A 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 s e 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 o ells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
0
9.Total well depth below land surface: 5 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I001 construction to the following:
10.Static water level below top of casing: C) 00 Division of Water Resources,Information Processing Unit,
If water level is above rasing,use"+" 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
d r above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,;Underground Injection Control Program,
FOR WATER SUPPLY°W�EGL NLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) '`' , Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
` f I the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: " 1 Amount: ` 6 8 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016