GW1-2022-01213_Well Construction - GW1_20220103

r vrrrr
WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor information:
A�� 14.WATER ZONES
weucnmractorlme FROM TO I DESCRIPTION
?d 4 1 ,;tt:
NC well Contractor Certification Number '
1 15.OUTER CASING for multi-cased wens OR LINER rta ble
FROMf� DIAMETER in. 1EICHNESS MATERIAL
� �
_
Company Name a G
2.Well Construction Permit#: l&A 0 b 1R INNER CASING OR TUBING thermal el CKN oo
FROM TO DIAMETER TBICKNF.SS MATERIAL
List all applicable well construction permits(La UIC,County,State,Variance,etc.) IL ft- in
3.Well Use(check well use): & ft- to.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SL40TSM THICKI MATERIAL
Agricultural DMunicipal/Public U fir. & ID'
Geothermal(Heating/Cooling Supply) residential Water Supply(single) R ft, is
Industrial/Commercial Residential Water Supply(shared) I&GROUT
jai. ion - FROM I TO MATERIAL CENIENrAW flOD&AMOUNT
Non-Water supply well: Q ft. fl �4 r e,Q
Monitoring Recovery 3 ft. f1.
Injection Well:
fz IL
Aquifer Recharge [3Groundwater Remediation 19.SAND/GRAVEL PACK Of applicable)
quifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage fL ft
Experimental Technology [)Subsidence Control IL L
Geothermal(Closed Loop) Tracer 20.DRII LING LOG attaeti'ddiflonal sheets if necessa
Geothermal(Heating/Cooling Retum) er Oth (explam under/t21 Remarks) FROM To D ON color, solhock SEW.etc
R 'tt
4.Date Well(s)Completed: 6 -wen ID# 1 D R '; , tP r j !
5a.Well Location:
�� 11. 1L
air
R: R
Facility/Owner Name F- ity ID#(if applicable) n ft'
�I �t�ltst�1 ilc arr�i lam .. vl� s�tl n1G ��53 & JAN 0 3
Phy\si`cal/Add[esi.City,and Zap L 0110
n iL
96- l T�10� I 2L REMARKS„
County Parcel Identification No.(PIN) Ii 11 LttivS t1 `�' �✓ `�{f1)(y I '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat4ong is sufficient) 22:Certification:
_N -7-7 0 W iiat,, 93"
30
6.Is(Are)the wells) ermanent or DTemporary SigWtureoftertifiedWellOontractor Date
By signing this form.I hereby certify that the well(s)was(were)constructed in accordmice
7.Is this a repair to an existing well: [3Yes or J4No with 75A NCAC 02C.0100 or 15ANCAC 02C.0200 well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy ofthis 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:
'You use the back of this page to provide additional well site details or well.,
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same may
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:�' 7 ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dlfjerent(example-3@200'and 2@100) construction to the following:
.
10.Static water level below top of cos ' �mg: (R-) Division of Water Reso tirces,Information Processing Unit,
If water level is above caring,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)- 24b.For Infection 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 we]
W.� 7l
12.Well construction method:- M41 RO1
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 Mara Service Center,Raleigh,NC 27699-1636
13a.Yield(Win) Method of test 24c For Water Supply&Infection 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: 1 A.t: completion of well const<uctton 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
f