GW1-2021-02735_Well Construction - GW1_20210805

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WELL CONSTRUCTION E ORD GW-1 Far Intemal Use Only:
1.Well Contractor Information:
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Well Contractor Name FROM TO DESCRIPTIONtft/e ft. 5 � ft. �
V ft
NC Well Contractor Certification Number j ,Q1II Eft CA3#�1G for tnulftaetttirells #it7iR tf le
�Ie Brothers Inch FROM TO DIAMETER THICKNESS MATERIAL
ft, ft. in
Company Name IUC XJLWY268 W
16.T(Y1!IER,CASIN6QRTti13I1�1G" abtliernaatilo$iSo ,,.`:,r :'.:
Z.Well Construction Permit#: k g NC 28621 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits .'.UI ,County,State.Variance,etc) ft. 8
3 ft. �C 7 in.
3.Well Use(check well use}: IL
Water Supply WeII:
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply esidentiai Water Supply(single) ft ft. in.
Industrial/Commercial esidential Water Supply(shared) 18 OBOUT
"Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft- 2.3 ft-
Monitoring ecovery ft. it-
Injection Well: �#4y?
ft. ft.
Aquifer Recharge roundwater Remediation
19.SA1VD/6RAVEi,PACK* f' 'licaltile. ,
Aquifer Storage and Recovery 13
alinity Barrier FROM I To MATERIAL I EMPLACEMENT METHOD
Aquifer Test 0 tormwater Drainage ft ft.
rock type,grain sire,etc.)
Experimental Technology [3 ubsidence Control ft. fa
Geothermal(Closed Loop) [3 Fracer ZB:IiRti.fslt!TGLOG:"attai�iit4' It0 f t
^
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardn soiU
ther(explain under#21 Remarks} ft ft.
4.Date Well(s)Completed: ?— ZZ' Well ID# ft ft
59.Well Location: p ft ft.
!� �, eel� ft ft. 1JLo
/
F`accility/OwnerName + Facility ID#(if applicable) ft ft t3
'fN tA,S S i Ft it
Physical Xddress,City,and Zip ft. ft.
°SI<ItEiNA1ZK5 ;'y r
G �� 5 ,
County Parcel Identification No.(PIN)
56.Latitude and!cogitate in degreesh nut lsecoads or decimal degrees: infirmation processing
Unil
(if well field,one lavlong is sufficient) 1 22.Certification: DWR e
1 N I( �j' 13 ' 3 ' w ,..w. 7=2 2,1
6.Is(are)the well{s} er.anent or emporary j 4"1Q t Signature of Certified Well Convector Date
By signing this form,1 hereby cent that xhe well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Ye or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair.fill out known well constnictl info)nation 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 bac f thi form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Cl (osed-Loop othmal 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 ate I OTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J G t3 t (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welts list all depths ifdifferent(ex ple- -M200'and 2Q100} construction to the following:
10.Static water level below top of casin too (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (i } 24b.For Iniection 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 well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center;Raleigb,NC 27699-1636
13a.Yield(gpm) etho I of test:_ r 1^ 24c.For Water Supply&Iniection 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: A mount: V Z h.— completion of well construction to the county health department of the county
where constructed.
—7 17
Form G W-I N It Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016
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