GW1-2021-02739_Well Construction - GW1_20210805

WELL CONSTRUCTION�E ORD GW-1 For Internal Use Only:
1.Well Contractor Information:
L i4.WA4FAZOM -� :.
Well Contractor Nknc
FROM TO : DFSCRIPTION
a6 ft. V ft.
3535
i ft
NC We]I Contractor Certification Number .
ewman Brothers Inc. FROM T4 DIAMETER THICKNESS MATERIAL
1 ft. ft. in.
Company Name t.>, ..
��s� ��o '.1§:i�IVNER'�-`i4S�t3Vf (Jlt`, _ ,,... r>:` .:.v�,d .x,i•:
2.Well Construction Permit#: Elldn NC 28621 FROM TO DIAMETER THICV-NESS I MATERIAL
List all applicable well construction permits(1.k.U! Coun(y.State. Variance,etc.) f6 !_ fL �,f`4 y��
3.Well Use(check well use): ( p R GP fL in.
/!1
Water Supply Well: {I17:SGREEN. r
FROM I TO I DIAMETER I SLOT SIZE THICKNESS I MATERIAL
,bxglicultur-al unicipaYNblic fL
Geothermal(Heating/Cooling Supplyy esidential Water Supply(single) ft ft.
Industrial/COrnmercial { esidential Water Supply(shared)
AS.:GROUI'
Irrigation FROM TO MATERIAL_ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Z ft ea .' t
Monitoring !I ecovery fL ft.
Injection Well:
i ft. ft.
Aquifer Recharge Oroundwater Remediation
I llmbk
Aquifer Storage and Recovery alinity Barrier `-409SANWGRAYRL PAC#CiFROM To I MATERL41 EMPLACEMENT METHOD
Aquifer Test 5tormwater Drainage ft. ft.
Experimental Technology j 13 ubsidence Control ft. ft.
Geothermal(Closed Loop) otracer 1A D1tTLIIDt2ic1G sidlxgsa7" -
Geothermal(Heating/Cooling Return)ir3 ther(explain under#21 Remarks) FROM ft. ft.TO DESCRIPTION(color,hardness,soillrecklype,grain sloe,etc.
4.Date Well(s)Completed: 7—Z9"14 Well ID# ft ft. arm
5a.Well Location: ft_ ft.
u 1l r t1 ;��Y r1-ti fL1 Z
Facility/Owner Name j Facility ID:(if applicable) ft. ft.
L.+ra-55 GIr'l t. f QG�I"r ft fL
Physical Address,City,and Zip ft ft.
j{
County Parcel Identification No.(PIN) 1
Sb.Latitude and longitude in degrees/titfnut /seconds or decimal degrees:
(if we]]field,one lat/long is sufficient) j10
jj q 22.Certifica' n: ��LQn C�gG
.Avot
W ¢` /-30 -t I
6.Is(are)the well(s0fermisment 0il�13 remporary /,/3�'�
Signature of Certified Well Contractor Date
'
�!g BY signing this form,!herebv certifY�that the xell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: U Ye or Df�o with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Constriction Standards and that a
ythis is a repair.fill out known well constructiah info ration 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 bjth' form: 1%,
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop 41�ft 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-I is needed. Indicate TAL NUMBER of wells construction details. You may also attach additional gages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
t
9.Total well depth below land surface:i i (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(ewi4ple- 200'and 2Q1001 construction t0 the following:
10.Static water level below top of casing 3 , A (ft,) Division of Water Resources,Information Processing Unit,
0'water level is above casing use 1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter: ' (i } 24b.For Injection Wells." In addition to sending the form to the address in 24a
J, ,} /� above,also submit One Copy of this formtivithin 30 days of completion of well
12.Well construction method: 4.% t /�t f 1^ g
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,Raleigh,NC 27699-1636
13a Yield(gpm) �� *tho of test: t 7 24c.For Water Supply&Injection Wells: In addition to sending the form to
��f' the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:-�it ount: 1 2— "� completion of well cons caton to!the county health department of the county
where constructed.
Form GW-I ? 1
N4 rth Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I+I