GW1-2021-02110_Well Construction - GW1_20210706

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WELL CONSTRUCTION CORD GW-1 For Internal Use Only:
1.Well Contractor Information: '
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V
I WA`CERZOIVES
O 2�21 FROM TO " •""
Well Contractor Name DESCRIPTION
4-4�, JUL ao ft. oft.
NC Well Contractor Certification Number �at�n prO�g�Sln�V It ft ft.
in(G[I„ , 25:UTEIEA`�aSth(G, uu>lt=t !e1kUs;O1t?TtEIi'" ," t . ,.
m p��a is 5e sort FROM TO DIAMETER THICKNESS MATERIAL
ft ft. in.
Company Name
p ."24'.`��F�t=Gi4.SI1VG�It' B111G�"„"„
2.Well Construction Permit#: WS D Z Q 1�O FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i. .I UIC, County.State. Variance,etc.) �—' ft. O O It. 15-7 b in. 1/U
3.Well Use(check well use): I ft ft in.
Water Supply Well: .,SCRE&N. ..
FROM I TO DIAMETER 'SLOTSIZE THICKNESS `MATERIAL
Agricultural unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 0 esidential Water Supply(single) ft ft in.
Industrial/Commercial O esidential Water Supply(shared) ;g GROAT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft Z ft, t ` d
Monitoring I 113,Xcovery ft. ft• R o rH en/1
Injection Well:
Aquifer Recharge 13 roundwater Remediation
19.SANDlGRr1VEi;'PAC1C rf '"lieiibie :.
Aquifer Storage and Recovery alinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3 tormwater Drainage ft ft.
Experimental Technology 13.1 ubsidence Control
Geothermal(Closed Loop) I racer 26 DTtI1J17NG I OG""aticJl'talilHle 'SDeets`3[::ceci �"" 'r" •;
FROM TO DESCRIPTION(color,hardness,sollfrock e, gain size,etc.
Geothermal(Heating/CoolingReturn) ther(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: L o- Well ID# ft ft
Sa.Well Location: ft. ft
ft. ft.
bhd rt. 1 )yf m n-)
Facility/Owner Name Facility ID#(if applicable) ft. ft
L . f. ft.Physical Address,City,and Zip J ft. ft.
U LtW�, ?"► 2fTFElP1A�tK5
i
Co ty Parcel Identification No.(PTN)
5b.Latitude and longitude in degrees/ ut /seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification:
6.Is(are)the wells) ermanent o [3 emporary G' 00 j Signature of Certified Well Contractor ' Date
` By signing this form,1 herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Y(s or To with 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construct"iQ info Cation and explain 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 thi form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop eoth rmal 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. In di cate TOTAL NUMBER of wells construction details. You may alsot'attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS l
9.Total well depth below land surface: 2 a 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(exla ple- @200'and 1 ct l00') construction to the following:
10.Static water level below top of cas(d : (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use l+- 1617 Mail Service Center,Raleigh,NC 27699-1617
3 i
11.Borehole diameter: ( •) 24b.For Infection Wells: In addition to sending the form to the address in 24a
ll above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: (y T construction to the following:
(i.e.auger,rotary,cable,direct push,etc.
Ill Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONL : 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 1 Vlethd of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
2( the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: Amount: i '� completion of well construction to the county health department of the county
where constructed.
Form GW-I Jorth Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016