GW1-2021-00768_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Lam `n ',i�II�I -sY 14.WATER ZONES
Well Contractor Na a FROM TO DESCRIPTION
q 0�ft. a ft. 11 �JIA
O(]v( Ir�I ft. fL
NC Well Contractor Certification Number
15.OUTER CASING for multi cased wells OR LINER( sable)a licablc
FROM TO DL4METER TffiCKNESS MATERIAL
1111 VVVV1 \Company Name 1f�^l �+_k ft. oC -VA
11 O VNC,
�,�Q � 16.INNER CASING OR TUBING m colheral closed-too
2.Well Construction Permit#: FROM TO I DIAMETER TffiCKNESS I MATERIAL
List all applicable well construction permits(i.e. UIC,Count),State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:)Agricultural DMunicipal/Public cp5ft. a ft. in. M1 SC-h,k0 PV L
Geothermal(Heating/Cooling Supply) %Residential Water Supply(single) ft. vc ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Ini ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
ft. ft. �� t 1 ,^
Oak
Monitoring DRecovery
Injection Well: t�
ft. ft.
P-LAquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 17ISalinity Barrier FROM I TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test r.'IIStonnwater Drainage ft Oft # sa �r
Experimental Technology []I Subsidence Control ft. ft.
Geothermal(Closed Loop) []ITracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,ete.)
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) ft. ft
4.Date Well(s)Completed: , v1D Well ID# ft. -1 ft
Sa.�Well
(�Location: ft. ft. AcIr\ G
ft.
�ft. U,n ln1 t
Facility/Owner Name Q� Facility IDD#(if applicable) �C t QQ ft. h
R1t 1 �e CCQS f�li1 R o mm i - � _-% ft. �L� 10 ft ` V.�
Physical
Address,City,and Zip ft. ft.
npci�� 21(.REMARKS County Parcel Identification No.(PIN) W1� �5 "Q
2021
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one lat/long is sufficient) 22.Certification:
N 'f
�� .��0 \3� W i r
6.Is(are)the wells) Permanent or MTemporary Signature of6irtified Well ntractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a•repair to an existing well: E)Yes or No with 15.4 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 nd 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 t&s.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.
drilled. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 40 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3 a200'and 2@I00') construction to the following:
10.Static water level below top of casing: (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 Iniection Wells: In addition to sending the form to the address in 24a
l above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: .1 t,�n`V(� � 1(\/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: Zp��) 24c. For Water Supply&Iniection Wells: In addition to sending the form to
u the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ' 1� Amount: rLk 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