GW1-2022-09160_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
60V,V11e-+t
Well Contractor Name V FROM TO I DESCRIPTION
LIS Ll 5-,A-
ft. ft.
NC Well Contractor Certification Number
FROM TO I DIAMETER MATERIAL
ri S
Company Name ft. 100 ft. eye.
2.Well Construction Permit#: 2, FROM TO I DIAMETER THICKNEB8 MATERIAL
List all applicable well constructlonpernilts(i.e.UIC.County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. j
Water Supply Well:
:]Agricultural 13MunicipaYPublic FROM I TO I DIAMETER I SLOT SIZE THICKNESS MATERIAL
R. I it. I � In. I
:3Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. rL In,
:]Industrial(Commercial [3Residential Water Supply(shared)
RIM
—111trigation I MATERIAL EMPLACEMENT METHOD&AMOUNT
—1 FROM TO
Non-Water Supply Well: LO `L
3Monitoring E3Rccovery
Injection Well:
Aquifer Recharge [3Groundwater Remediation
OMOUN
MM
NOWMCOMM
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer lGeothermal(HeatinglCooling Return) ClOther(explain under#21 Remarks FROM TO DESCRIPTION(color,bardoess,saillrock typei grain mlz etc.)
0 ft. I o ft. C.)a-V
4.Date Well(s)Completed: Well IDN To—tift. 6 rc ,i I e-
Sa.Well Location:: Q 1 ft, ft.
la ft. ft.
J. 'Oul-e, Scoff-
Facility/Owner Name Facility ID#(ifopplicable) ft. ft.
170 14--i'd A t*A Va 1.(&.&g: Or. ft. R. SEP 11
Physical Address,City,and Zip ft. ft,
n;1
C P0 vy-p- I I 7, =
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lattiong is sufficient) 22.Certification:
5641757 N 9 74t 6 w &
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified W611 Contractor(-) Date
By signing this,/burr,I hereby certyy that the ivell(s)was(were)constructed In accordance
7.Is this a repair to an existing well:* 13yes or 4ONo with 114 NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthir Is a repair,Jill out known well construction 14forination and explain the nature ofthe copy 41`1h1s record has been provided to the well owner.
repair under#21 remarks section or on the back ofthisform, 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 details. You may also attach additional pages if necessary.
construction,only I GW-I is needed. Indicate I a TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Well Submit this form within 30 days of completion of well
For multiple wells list all depths(fdoerent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of easing: (ft.) Division of Water Resources,Information Processing Unit,
Ywater level Is above casing.use"+" 1617 Mail Service' Center,Raleigh,NC 27699-1617
11.Borehole diamiter: ID On.) 24b.For Infection Wells: ln;'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: g4u 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
13a.Yield(gpm) Method of test: y- 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(cs) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Iggy-i I&f, Amount: 2 C,-12 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division/of Water Resources Revised 2-22-2016
/11).t. 1 , -A— . / --z--A A r--i i i i , - -