GW1-2021-00790_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
ka rr id)r G {� 14.WATER ZONES I
FROM TO DESCRIPTION
Well Contractor Name 1 ft. 9 ft. ' � s
Q /Q01
Of r u
2 0 b3�rl ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased*ells OR L1NER if a 7icable
r `• I �� 'Pro
l FROM TO DIAMETER THICKNESS MATERIAL
Company Name Q 'P ,- I ft. rl l ft. a in. s'CH'(• o PVC
16.INNER CASING OR TUBING cotherntal closed-loo
2.Well Construction Permit#: 2 7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) ft. ft. in* [G11� VC+
3.Well Use(check well use): ft. ft. in. J U
T�
17..SCREEN,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATE RIAL
J Agricultural [3Municipal/Public 1 ft. 2q ft. a p t m �f SC1, -t1 Ll
UG
_i Geothermal(Heating/Cooling Supply) 1wesidential Water Supply(single) l ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) -
18.GROUT,
_—)Irrigation FROM TO MATERIAL 1 EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. 0 ft. n t T-e 3 o t! u S
Monitoring DRecovery ft. ft.
��
Injection Well:
ft. ft.
_ Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a licablc
Aquifer Storage and Recovery r.IISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
61
Aquifer Test OStonnwater Drainage p ft. �r An VU r yu.
Experimental Technology M ISubsidence Control ft. ft.
Geothermal(Closed Loop) rJITracer 20.DRILLING LOG(attach additional sheets if necessary
FROM Geothermal(Heating/Cooling Return) IOnnther(explain under#21 Rem TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
arks) ft. SO1'
4.Date Well(s)Completed: —101A)Wel1ID# ft. C/ ft. R ri c1Q
5a.Well Location: 9 ft. Z C ft. n G a
1 Qn Don►,-e is ft. a ft. h,- a.t
Facility/OwnerNamee fj / a Facility ID#(,i/f�ap/p�licable) a ft' 5— ft' )ad, G)
AV y C Jrit�f���N �!/I DuA n lyc fL ft.
Physical Address,City,and Zip /� ft. ft DEC
�e4 MPS6�✓ 11 Bsl Z2 06057 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if welll field,one Ij /atAong is sufficient) 22.Certification:
30 0 11,
- /-y I N 0 �I^ 41S_� W f -/V- 47,0
6.Is(are)the well(s)16
Permanent or OTemporary Signature of C fied Well Con Actor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or o with 15A 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 Wngdexplain 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.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a200'and 2@100') 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 fotm to the address in 24a
y� u r / above, also submit one copy of,this form within 30 days of completion of well
12.Well construction method: /+1 (�( ry�(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 01. Method of test: DUA110111CI 24c. For Water Supply&Iniection 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: �-� completion of well construction to the county health department of the county
where constructed.
f
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016