GW1-2021-00688_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
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Well Contactor Name FROM TO DESCRIPTION
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NC Well
Contractor Certification Number ppp / :; ;i), A6IdsIG tol antiltl�asedr'' l :®11° llYElt "' eafil
P �� I �, FROM TO DIAMETER THICKNESS MATERIAL
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Company Name ^ 1Yn 1�liC bPE=111B1Nf `' hk�tliRliil6Sf d±14771;;77
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2.Well Construction Permit#: 0 0.J 0 P-3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Varid0e,etc.) ft. fG In,
3.Well Use(check well use): In.
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Water$upplyWell: FROM TO I DIAMETER SLOT SIZE THICKNESS MATERUL
Agricultural rIMunicipalftblic
Geothermal(Heating/Cooling Supply) ffResidential Water Supply(single) ft, in.
IndustriallCommereial Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMFiVT METHOD lb AMOUNT
Non-Water Supply Well: 0 % if
Monitoring 13Recovery ft. fL
Injection Well:
ft. ft
Aquifer Recharge ®Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL EMPLACEMENT`METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. ft.
: ,atf¢Yddttlba BheSt3ritYE 3s fi7777,
Geothermal(Closed Loop) Tracer 30: T a i_:y ..,u77
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks FROM TO DESCRIPTION color,bardnes soil/rock type,gmin slz etc.
4.Date Well(s)Completed: a -�3.a I Well ID#
5a.Well Location: 150 it. (TO fr.
ple.n h ,h✓1 ft ft.
Facility/Owner ame (if Facility ID# applicable) fL ft.
t o It Lk Ca 4L ft. ft.
t Physical Address,City,and Zip ft. ft. 2 20
fit,. A
County Parcel Identi ationNo.(PIN) rrr
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
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6.Is(are)the well(s) Permanent or OTemporary Signature of ed Well Contractor bate
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: []Yes or JdNo with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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 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 construction details. You may also attach additional pages if necessary.
I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I O 00 24a. For All Wells: Submit this it form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200 and 2@1001 construction to the following:
10.Static water level below top of casing: U (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
It
11.Borehole diameter: (in.) 24b.For Iniecdon Wells: In addition to sending the form to the address in 24a
a 1 FQ / 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 WELLS ONLY: II..11 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) a f" Method of test: W 24c.For Water Supply&Inlection,Wells: In addition to sending the foam to
r the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:1A r1 Amount: 2 l completion of well construction to the county health department of the county
where constructed.
Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016