GW1-2022-01769_Well Construction - GW1_20220223

WELL CONSTRUCTION RECORD(GW-1). For Internal Use Only:
1.Well Contractor fo lion:
y 14.WATER-EONES
Well Corfi2tYor Name FROM TO DFSCRn'rtON
3c9R
Y R �
NC Well contractor on Number
ta.ouTER. for matti�ed; .' oR tMER.d
FROM TO DIAMETER I THICINEW MATERIAL
R R in.
Company Name /
S� 16 1tN1�R.CtiSII�7G.O1t7BnvG
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all appltcoble well construction permits(r.e.UIG County,State.Variance,eta) R in'
I/C
3.Well Use(check well use): ft- D R in. V
Water Supply Well: 17 SCREEN'
FROM TO I I DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
Agricultural 13Munic lic O R in
Geothermal(Heating/Cooling Supply) idential Water Supply(single) zt
in
Industrial/Commercial QResidential Water Supply(shared)
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD 8 AMOUNT
Non-Water supply Welk 51ROV
('� R• C Oil
Monitoring Recovery R
Injection Well:
R
Aquifer Recharge t]Groundwater Remediation Rh 'PACK
Aquifer Storage and Recovery [)Salinity Banter MATERIAL EMPLACEMENT METHOD
Aquifer Test' DStormwater Drainap fLExperimental Technology Subsidence Control RGeothermal(Closed Loop) TracerGeothamai tm Cool Redun) Outr( lain under#21 Remarks TO D N color iv+�ess.smWk dm,eta R
4.Date Well(s)Completed: I ,Well 1D# O R c f0 R
0
Sa.Well eatio ft' R'
R R
Facr!i /=Name/ Faw7i -M#(if ap71'e
.. fL R42 h C©M A�? �/t Q R R
Physical ,City, d Zip R &
2LIMIKARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degmes/minutes/seconds or decimal.degrees:
(if well field,one lat/long is smfficieot) 22.Certification: n
W
6.Is(are)the wells) Permaneut or Temporary Sipoatme ofCeaified Coattactor Date
By signing this form,I hereby certify the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or o with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
1f this is a repair.Jill out btown well construction irformatian and explain die nature of the copy of this record has been provided to the well owner.
repair render#21 re mart swam or on the back of dusfotm. 23.Site diagram or additional well details:
8.For GeoprobeMPT 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: G/ () fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For muldple wells list all depths#f different(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing: (fL) Division of Water Resources,Information Processing Unit,
Ywater level is above casing use ,+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in-) 24b.For Injection Wells: In addition to sanding the form to the address in 24a
1L Well construction method:
above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auga,rotary,cable,direct push,etc)
Division of Water Resources,Underground Injection Control Program,
L13&Yield
ER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
(gpm) hfetitod of test i 1 P 24c For Water StrnDiv&Ini lion Wells: In addition to sending the form to
the addresses) above, alsoty within30 days of
fection type: Amount: `l7� completion of well const uctio t�to e ' ty• Cd ent of the county
where constructed.
FEB 2 3 2022
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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