GW1-2022-01716_Well Construction - GW1_20220207

WELL CONSTRUCTION RECORD(GW 1) ForInteraal Use Only.
1.Well /ntracctor Information:
�/�
�` / r✓L �" lC WATER ZONES'
Well Contractor Name FROM TO I DESCRIPTION
Gi'f it.
2y7-ft. 4
[L ft
NC Well
�Contractor
�C.er/tifiicationNumbeer l
��v , Well II,I/I 9 I&OUTERCA&INGtfor'riiutti-eased:wells ORLINM _ .livable
11FROM TO DIAMETER TffiCKNFSS MATERIAL
Company Name T� R' Q [t in
��I Q L 16.IIVNER CASING OR Tt1BING eotheraW closed-loo
2.Well Construction Permit#: _K.7 FROM TO DL M 7M I THICIMM I MATERIAL
List aU applicable well construction permits(i.e.UIC.Cormil;Stang Variance,eta.) % ft. in.
3.Well Use(checi weII use): tt fL in,
Water Supply Well: :17:5CREEN
FROM To DIAMETER SLOT SIZE I MATERIAL
Agricultural [3M cipaUPubiic ft % in.
Geothermal(Hcating/Cooling Supply) eside�tial�Wate:r Supply(single) ft. ft. in.
1ndustriaUC0mmercial DResidential Water Supply(shared) GROUT
Irrigation
FROM I To MATERIAL F"LACEM M OD&AafOMr
Non-Water Supply Well: ft. ZO ft,
P ed
Monitoring Recovery tt. ft
71
1"Cicothermal
jection Well:
Aquifer Recharge �GrormdwaterRemediation R. fL
19:SAND/GRAVE),PACK a IIcable
Aquifer Storage and Recovery ®)Salinity Barrier FROM To MATERIAL EMP LACENtENT METHOD
Aquifer Test OStonnwater Drainage fL ft.
Experimental Technology ®)Subsidence Control & ft.
Geothermal(Closed Loop) Tracer 20:DRII;LING LOG(attach additional sheets if necessa(Heating/Cooling Rectum Other lain under#21 Remarks) //FROM To DESCRIPTION color hardness,soiVroca tutu sim etc.
V R' 75 ft. 1t
4.Date Well(s)Completed 0+Z0'21 Wea ID# G ft 4W ft !'�
Sa.Well Location: R• ft.
_�eoraC A. � '1S ft. ft. `Z!s
� : s
Facility/ crrName Facility M#(if applicable) R R• [^
r1rS1- D,. 1 on WOtI�I PrGrCPt /Io'�✓�i'�"tTPfPtro» & r
Physical Addrlcssss,City,and Zip Z W91f ft ft
21 - .
aRLMARKS
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.Certiftcation-
o-z9-a/
6.ls(are)the well(s)�rmanent or Temporary Signal,.ofCertified ntractor Date
By signing this form,I heieby certify that the we (s)was(maem)constructed in accordance
7.Is this a repair to an existing well: E3Yes or Pals". with 15A NCAC 02C,0100 or 15,4 NCAC 02C.0200 Well Construction Standard;and that a
If this is a repair,fill out known well construction information and uplam the nature of the copy of this record has beenprovided to the well owner.
repair under#21 remarks section or on the bark afthis 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:
a/1 depths
/��IY��' SUBMITTAL INSTRUCT[ONS
Forr multiple wells U
9- i well depth below land surface:qW (ft-) 24a. For All Webs: Submit this form within 30 days of completion of well
multiple wells uGfferent(crumple-3Q200'and 2(a3100� construction to the following:
!f;W
ffi Static water level below top of casing: �Od� (ft.) Division of Water Resources,Information Processing Unit,ier level is above casing,use"+" g t,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: t�s Ve
ern') 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: {f RArtf above,also submit one copy of this fort within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc,) { construction to the following.
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Z 1 Method of test: 1 24c.For Water Supply&Infection Wells: In addition to sending the form to
RAU0 Z the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: Amount: p 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