GW1-2021-02452_Well Construction - GW1_20210805

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only,.
1.Well Contractor Information: /
.14.:WATERZONFS
Well Contractor Name FROM TO AFSCRIPTIIN
Y&.s-4- 41a6
ft ft. . .
NC Well Contractor Certification Number r15.OUTFE:CASING foriaaltieaieil:wells ORLiNER da"ntsble::,a:;;;.. .,'.:;:...
F, FROM TO DIAMETER T�C[QIFSS MATERU►L
1C .9// fo-b '. fit, ��y fib in.
Company Name
:16 INNER CASINGOR theemeletdsedluo :.;i,'naa.e,,<y.;y.•.•.:. ;rx
2.Well Construction Permit#: Q FROM - TO DIAMETER TRICIQVBSS MATERIAL
List ail applicable well conduction permW(Le.i/IG County.Stam Variance,eta) fL fL in.
3.Well Use(check well use): R' ft. 1°'
Water Supply Well:
FROM TO .']DIAMETER ry SLOTSIZE TmCIO M MATFdtWL
Agricultural []Municipal/Public 0 ft. ft is
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft
Industrial/Commercial residential Water Supply(shared) ;>18:GRODT�yF.
Urination ]FROM TO. MATERIAL 1EMPLACEMENTMEIHOD&AMOUNT
Non-Water Supply Well: Q R 1 lip
fL t.
Monitoring Recovery ft. ft. 4
Injection Well: fL ft
Aquifer Recharge Groundwater Remediation
�:19:�SAND/GRAVEI:PACK tfa Timbte E r><:-,•,'"::.�:t:::'::%,.i:..:.:,Jx:.:;.;_,<.....i:C:...<r.
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL FM1ipLACBMFJVT METHOD
Aquifer Test OStomtwaterDrainage ft fL
Experimental Technology Subsidence Control ft fL
Geothermal(Closed Loop) E3Tacer j2Q'DRIGLINGLOG attaehsMdifc6oil'abeeaR ' :.CJslr=,:.;:,a::,M,.::,...
Geothennai(Heating/Cooling Return) nOther(explain under#21 Remadrs) FROM TO DFSCRI nOr4 color .Wr ct< etr.
ft-
4.Date Well(s)Completed: 7 -2 l Well ID# S�� �s tt it. d
5a.Well Location: R' 6 .3
Facnity/OwnerName _ Facility W#(Ifapplirable) fL fL
421 Y 24 4"&fv id i fL f.
Physical Address,City,and Zip / fit.fL
y Q
dx / e2IrRF11fARK35'J:tt.:> 4:sf^"r^• u'.'.}h .r z:�ti7;:::: :::'t Y.:. L:. -cam_.''..
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: °c@SSIn
(ifwen fold,one lat/long is sufficient)41- III° CJgC(1
22.Certification:
�i�db J t�a s'� ��'�f /�l`/13 `7 w Old
6.Is(are)the welt(s)[9vi"aneut or OTemporary S' of Wen Contractor Date
By s4ming this Am I hereby cw*drat the well(s)was(were)conbucted in axordmrce
7.is this a repair to nn existing well: ElYes or 10 +vith 15ANC4C 02C.0100 or ISANCAC OZC.OZW Well Construction Smtdmds and drat a
Ythis is a repair,fill out known wellconstrucdon information and explain the nature ofthe copy of/hisreaoAffmbeenpmv/dedto the sve(lmow.
repair under#21 remarks section or on the back ofd4r form 23.Site diagram or additional well details:
9.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
9.Total well depth below land surface: (fL) 24a.Por All Wells: Submit this form within 30 days of completion of well
Formaldple wells li t all depths lfde'am(exmnple-3 a@200'and2@1003 construction to the following
10.Static water level below top of casing: / (ft.) Division of water Resources,Information Processing Unit,
Ifwater lewd is above crash+&use"+" 1617 Mail Service Center,Raleipty NC 27699-1617
11.Borehole diameter: (in_) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 0 3/ above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cabin direct push,eta) construction to Ste following
Division of Water Resource,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /00 Method of test: �.'1 1 24c.For Water SuDDiv&Infection!Wells: In addition to sending the form to
the address(es) above, also submit one ropy of this form within 30 days of
13b.Disinfection type: 9r-4 rL.- Amount: © Z . 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
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