GW1-2022-01135_Well Construction - GW1_20220103

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
s?YV�1 t7 aIC,:WATER....ZONES ,:-
WellCon�ame FROM TO DESCRIPTTON
�/KQ 3 ft. ft.
NC Well Contractor Certification Number
15.(OUTER CASING for could-cwe'd:Fcells UR>LINER if a !feeble
In,
1"/ a�� �' t M'ROhI 'I'O IIIANI NTI'N;R. 't'nICKNN;$S M.4'1'F;R/I�AI.
I�f 1 �1` 'r fL ft. m y-1 D O VCR
Company Name !r
�il�,?1J? �9�5�0 16.< ER.CASINGUR TliB1NG cothcrthakclosed-lao'
2.Well Construction Permit#: FROM TO DIAMETER TffiCKNESS M.ATERIAI.
List all applicable well construction permits(i.e.UIC,Count',State.Yuriance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
t7.SCREEN
..
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in,
e Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft. fc,
industrial/Commercial OResidential Water Supply(shared)
��'OUT .'.,,
--- -- -
irrr a[IOn FROM 1 "1'0 DIA"I'F.RIAI. EMPLACEMENT MF.THOn&ADIOUN'I'
Nun-Water Supply Well:
Monitoring Recovery lJ ft2to ft. en 1_
Injection Well: 7t)
ft. ft.
Aquifer Recharge 06roundwater Remediation .. . .
.19.-SANDIGFt#;vEL-PACI{=rf"a'lltlrible)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEDIENT METHOD
Aquifer Test 13Stonnwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 2d.DRILLIN(�LOG attach'additiortalsheets faecessa
FRO" TO DESCRIPTION color,hardness,soillrock type.gnin size,etc.
Geothermal(Heating/Cooling Retum) Other(explain under#21 Remarks) 12 ft ft. C
4.Date Well(s)Completed: ),7—DIWell iD# A_ 8'ft.
fL ft. Ala t
5a.Well Location: Q Q _
W wahz �X1i71'Q SS ft. ft. \C A
Facility/Owner Name �— Facility ID#(if applicable) ft. ft.
Physical Address,City,and Zip Ct ft
n
( 2lyd IL zL;trEMAP
s
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
�35`�D •�'3� N am° I,&2-7 _W
AW, 5-27- 2�
6.Is(are)the weU(s) ermanent or Temporary.. signature o .ertified Well Contractor Date
� By signing this/brnn,I hereh)v ccrtifj,that the svellfs)Iran(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or E „V with 15.4 NCA(:02C.I1100 or 15A N(:AC 02C.0200 Nell Construction Starulards and that a
If this is a re pair.1111 out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 921 remarks section at-on the back of this horn.
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
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9.Total well depth below land surface:4o (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i/'diJjerent Ierample-3(a�'00'and 2(u 100') construction to the following:
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10.Static water level below top of casing: 4J 1) (ft.) Division of Water Resources,information Processing Unit,
1%writer level is above casing,use "+" 1617 Mail Service!Center,Raleigh,NC 27699-1617
11.Borehole diameter: `j 24b. For Injection Wells: In addition to sending the form to the address in 24a
n above, also submit one copy of this form within 30 days of completion of well
212161,
12.Well construction method: F-il Y construction to the following:
(i.e.auger,rotary,cable,direct push,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service�Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 12 Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
j� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: yi r, Amount: Cif completion of well conshuctionh to the county health department of the county
where constructed.
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Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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