GW1-2022-09361_Well Construction - GW1_20221010

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WELL CONSTRUCTION RECORD(GW D For Internal Use Only: '
1.Weil Contractak Information:
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14.WATER1lANES-
Well Contractor m Nae FROM TO DESC 3MON
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NC Well Contractor CertificatioaNamber 1r-1r.ODT'Fdt CA3MG,(ttrt utuM area we os`>r><tvnK' ®bre
C— ;7 W 1`IJ I- D C J C. FROM TO DIAMETER T�C[U�IFSS MATERIAL
Company Name 1C L Ir 1 IV O ft. ft. SGµ q v
I6.fNNER CASING OR TQBING er I clamed-Ioo -
2.Well Contraction Permit#: FROM TO DMMEM I rm MAwmAL
List all applicable well construction permits CU.VIC,County.State,Variance,etc) • • in,
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN-
FROM TO DIAMETER I SLOT SIZE 17MCKNM I MATERIAL
Agricultural clpal/Public U ft. ft. iD.
Geothermal(Heating/Cooling Supply) _Residential Water Supply(single) ft. ft. ;II,
Industrial/Commercial E31tesidential Water Supply(shared) I&GROUT
Irrl ation - FROM TO MATERIAL EMPLACEMENT METHOD&AM01W
Non-Water Supply Well: D - 01
Monitoring Recovery ft. %
Injection Wen:
ft. ft.
Aquifer'Recharge 00roundwater Remediation
19.SAND/GRAVEL PACK fir applicable),
Aquifer Storage and Recovery Salinity Barrier FROM To I MATERIAL I EMPLACEMENT METHOD
Aquifer Test n Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRII.LII+IGLOG attach additional sheets ffneccssar�
Geothermal(Heating(Cooling Return) _ Other(explain under#21 Remarks) FROM To DESCRIPTION(mlm; swiftw k etc
I fL ft.
4.Date Wells)Completed: .2 �� -Wen ID# 'f 25 L4 ft. ft.
5a.Well Location: ft' &
Facility/Owner Name Facility M#(if applicable) ft. ft.
y H 9 d C H ug c-lA icE RD, ft. ft.
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Physical Address.City,and Zip ft, ft.
PCa5C u 21.REMARxS _ tr1
County t Parcel Ideutification No.(PIN) F n D C
IAT
5b.Latitude and longitude in degrees/minatedseconds or decimal degrees: F C
(if well field,one latllong is sufficient) 22.Certification:
34,.ysi 'i 'i N -79 ,0013t W MPA, Aviwxi
6.Is(are)the wells) Permanent or Temporary Signature of Certff ell Contractor Date
Bp signing this form,I hereby certify that the weA(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 62(Yes or ON. with 15ANCAC 02C.01W or 15ANCAC 02C.0200 Well Cnstrudlon Standards and that a
If this Is repair,fill out brown well construction informatlon and explain the nature of the copy of this record has been provided to the welt owner.
repair wider#21 remarks section or on the back ofthisform.
23.Site diagram or additional well details.
8.For Geoprobe/DPP 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: SUBMITt&L INSTRUCTIONIS
9.Total well depth below land surface: r2 o), (R•) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths If different(example-3Q200'aand 2@100) construction to the following: i
10.Static water level below top of casing: A) Division of Water Resources,Information Processing Unit,
Ifrmter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (0 Zy__(in) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Wen Construction method: O j PAZ above,also submit one copy of this form within 30 days of completion of well
t e au m construction to the following.
(' ger,rotary.cable,direct pusb,etc.)
Division of Water Resources,Undergmtutd n Control Progra
FOR WATER SUPPLY+ WELLS ONLY: _ 1636 Mail Service Center,gale g4lr; 9-1�35
13a.Yield(gpm) 1 S Method of test: P U rh P 24c.For Water Simply&Infection Wens:Ju'addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 6 b Z- completion of well construction to the county health department of the county
where constructrrd.
Form GW-1 North Carolina Depatmtent of Environmental Quality-Division of WaterRmool ws Revised 2-22 2016
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