GW1-2022-06803_Well Construction - GW1_20220715

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
P i N b i 0Q�/1,S I�l� 14.WATER ZONES !
WcllContta torNamc FROA1 TO DESCWTION
3 L1 I
NC Well Contractor Certification Number
15.OiTI'ER CASING for multi-cased wells OR LINER(ifars livable
Ikc FR Ai TO I D i THI S AL
Company Name ZZ U 1 n3 L1 A v'
4 16.INNER CASING OR TUBING acothcI'mal closed-loop)
2.Well Construction Permit#: FROM TO DL1hIETER THICKNESSV.ALITERL
List all applicable well constriction permits re.UIC,County State,Variance,e1c ft ft. in.
.J ,
3.Well Use(check well use): it. ft I in.
Water Supply Well: 17.SCREEN
FROAr TO DL1AM=. SLOT SIZE THIMiESS ALITERLl.I.
Agricultural DMunicipaUPublic 0 ft. fL in:,
Geothermal(Heating/Cooling Supply) &Residential Water Supply(single) ft. ft. ini
PIndustrial/Commercial Residential Water Supply(shared) 18.GROUT
hrigation FROM TO AMNERIAL EA CEAfENT 1%=OD&AAIOUAT
Non-Water Supply Well:
© n 3 rt. m t v+
Monitoring DRecovery 3 ft A 0 ft
Injection Well: -
Aquifer Recharge DGroundwater Remediation lt ft.
19.SAND/GRAVEL PACK(if applicable)
❑)Aquifer Storage and Recovery Salinity Barrier FROM TO AL\TERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control R• it-
Geothermal(Closed Loop) [3Tracer. 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FlOther(explain under B21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
ft. � rt -81:1� � SDI
4.Date Well(s)Completed: Q(a dD We11ID9 °�J�11 ID��� 40 n. g'O It- �n
5a..tW((e��ll Location: F0 n $ ft- �1 a-v ✓w�—�j q
l.Yl >�J 1ciQ S 8� rt. �s rt. ! _
Facility/Orrver Name U QA Facility ID#(if applicable) H" n• a P a . �V FEE D
(' � � tt ft. !,
G'��1 vim�stWs©�Q a�� t rJ(, �.�s dS
Physical Address,City,and Zip It. rL
G21'REMARKS
County Parcel Identification No.(PIN) �K•.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well Geld,one lai/long is sufficient) 22.Certification:
6.Is(are)the well(s)0I1'ermanent or Dl emporary Signature of C rtified Well C niractor yDate
By signing this form,I herebv certify that the well(s)is-as(ivere)constructed in accordance
7.Is this a repair to an exfsting wells Yes oi• §&No with 15A NCAC 02C.0100 or l5ANCAC 02C.0200 it ell Construction Standards and that a
if this is a repair,fill out knoitm ivell construction information and erplain the mature ofdre copy ofthis record iras been provided to the well owner.
repair under=21 remarks 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBXIITTAL INSTRUCTIONS;
9.Total well depth below land surface: I b c7 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ivells list all depths if different(example-3 a 200'and 2@100) construction to the following:
10.Static grater level below top of casing: a O (ft) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
I n ��yl above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: /C t P, construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,'Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
e
13a.Yield(gpm) 5' Method of test- 0 24e.For Water Supply&Injection Wells: In addition to sending the form to
e the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: ?i Amount: ri D 7 completion of well construction to the county health department of the county
41 where constructed
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources s I Revised 2-22-2016
1I