GW1-2021-00558_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
is WATER ZONES ;
Well Contractor Name FROM TO DESCRIPTION
�oZy _ - ft-
NC Well Cone ec(eor Cece6oe4on N.,mber Fs. LITER CASIlYG rmmtl' wells R LIIYSR llcable
FROM TO DIAhf&TSR TIncRNsss MA //R��w.
ft. ft. �i it in. Mt. V
Company Name .16.INNER CASING OR TUBING eotherand closed-loop)
2.Well Construction Permit A FROM TO DIAMETER I IMCKNESs MATERIAL
List al(applicable-11 construction permits(ie.UIC,Count)%Stale,Parlance,etc.) ft. ft. in.
3.Well Use(check well use):
Water Supply Wen: 41 SCREEN.
FROM TO DIAMETER SLOTSITS TMCENM MATERIAL
Agricultural � ICIpamblic p ft. ft.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft, ft. Ica
Industrial/Commerciai Residential Water Supply(shared) i&GROUT
Irrigation FROM TO MATERIAL FMPLACEIY mT METHOD&Amoumr
Non-Water Supply Wen: 17 ft• ft- /
M :onitoring Recovery ft. ft.
IWection Well:
_ Aquifer Recharge [3Groundwatar Remediation ft. ft.
SANDIGRAOEI PACK f. 'Bceble
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attachsdditiond dpths if
bye.yzin am eto
Geothermal eatin Coolin Return Other lain under 921 Remarks FROM TO DESCRIPTION color wluoetc
ft. ft.
4.Date Well(s)Completed: � Well ID91 ft. ft'
So.Wen Location:
acility/Owner Name Facility ID#(if applicable) ft. ft.
fL ft. -
Physical Address,City,and Zip ft. ft. I DEC 2 2
)?Crwny) 21.REMARES._.
County Parcel Identification No.(PR
Sb.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one/IaNro�ng is sufficieen�t)n � �� 22,Ce cation;
3 �1. 77Z & 7��5-9 �l/3'-lQ"w nn
6.Is(are)the well(s) rmanent or Temporary signs of Certified Well Contractor Hate
� By signing this form.I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing wen: 13Yes or E31`v with 15ANCAC 02C.0100 or I5ANCAC 02C.0200 Well Construction Standards and that a
If tots is a repair,fill out!mown well construction infbrmatlon 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 thisfirm.
23.Site diagram or additioaalwell 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 constriction details..You may also altach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total wen depth below land surface:
p 1-
(1) (ft.) 24a.For All Wells: Submit;this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@1005 construction to the following:
10.Static water level below top of casing: 7i 5' (tit.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 2769-0-1617
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: G�Q .,�A construction to the following:
(Le.auger,rotary,cable,direct push,etc.) C
Division of Water Resources,Undergiound bdecdon Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail SaTke Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: t M M^-, For Water Supply&Injection Welts: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Dishlfeetion type: ~r Amount: completion of well construction tD the county health department of the county
where constluawd.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22-2016
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