GW1-2022-03865_Well Construction - GW1_20220406

WELL CONSTRUCTION RECORD(GW1). For Internal Use Only:
1.Well Contraeto Inf lion:
d [ e. 14:-WAT ER-ZONES.
Well Contractor Name
FROM I TO I DFSCRWTION
R oo R ft U B.
NC Well Contractor CertiScazioa I&OUTER. foe motti-ems a OR IN(ER OF appli cable)
FROM TO DIAM THICKNM MATERIAL
Company Name
�-z & I k 0 ft. 1 4 � in. 'avc ' I
16.:01NER. t1RTfJBINO:
2.Well Construction Permit#: (/ Jam\ FROM: To I DIAMETER I TIHc[arEss MATERIAL
List aU appluaable well construction permits(Le.UIC,County,State.Variance,etc.) R & in-
3.Well Use(check well use): VIT & m
Water Supply Well: FROM E I To I DIAMETER SLOT SIZE I THICKNESS I MATERIAL
. Agricultural 99Mt 0419?ubliC O fL
A fL
Geothermal(Heating/Cooling Supply) /t�esiidential Water Supply(single) m
Industrial/Commercial 13Residential Water Supply(shared) ,-&GROUF:
Irrigation FROM I TO MATERIAL EMPLACXMFX METHOD&AMOUNT
Non-Water Supply Well: fL fL
vvt J
Monttormg E3Recovery fL ft
Injection Well:
ft. ft.
Aquifer Recharge 13Groundwater Remediation 19..SAND/GR&VELTACH )e
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test' 13Stormwater Drainage R A AL
Experimental Technology DSubsidence Control fL ffi i.
Geothemtal(Closed Loop) QTracer 38�RiI,L1N(s:LOG..attaehusdditie>mlaheeesif
FROM TO DESCREMON color, soWnKk am etr_
Geothermal(Heating/CoolingOther( lain under 021 Remarks
4.Date Well(s)Completed: t/ 2'.Well 110 5 R' GAR' b e�6Z
Sec.Well Location: ft
ft
Facility/thvuer Name Faeffity ID#(ifapplicabie) H •�",. d
Physicaln CirY ' •/�r•
"" �// ft. fL
.:2LREMARES
sn
County Parcel Identification No.(PIN) e A V,
y
5b.Latitude and longitude in degrees/minates/seconds or decimal degrees:
(if well field,one Wong is sufficient) 22.Certification:
W
6.Is(are)the wells) ermanlot or Temporary Signature of Certified Well Contractor Dade
By sighing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or o with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Sianda ds and Char o
[fthis is a repay,Jill out known wall construction information and explain the nature of the copy of this record has been provided to the well owner
repair rider#21 remarb section or on the back of thisform. 23.Site diagram or additional well details:
8.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: .�7 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For mtdttple wells&I all depths ttr4%rem(example-3 a@2 'and 2@1001 construction to the following:
R"
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
[f water lovel is above aasntg use'+^ 1617 Matz Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
�J �� -� 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,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
132.Yield(gpm) Method of test: r 24c.For Water Supply&Injection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: H Amount: completion of well construction to the county health department of the county
where constructed.
Forty GW-1 North Carolina Deparmtent of Environmental Qunlity-Division of Water Resources Revised 2-22-2016