GW1--03037_Well Construction - GW1_20230310

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WELL CONSTRUCTION RECORD(GW-11 For Intemal Use Only:
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1.Well Contractor Information:
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Well Contractor Name FROM TO DESCRIPTION
C 0ft ft i
fl ` ft. ft.
NC Well Contractor Certification Number ( �•
IANWrEieelLi RI
FROM TO
D THICIQYFSS MATERIAL
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Company Name
2.Well Construction Permit#: �q l I l p{FROM TO DlA51ETER THICENFSS MATERIAL
List all applicable well construction permits(i.e.MC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft It. in.
Water Supply Well: .. _
FROM TO DiAMErER SLOT SITE THICKNESS MATERIAL
Agricultural 13Mtmrci a - blic it ft In. -
Geothermal(Heatmg/Cooling Supply) idential Water Supply(single) it it in.
Industrial/Commercial Residential Water Supply(shared) 5r. -
_ _ _ >Y'••.� wYx_+ S.:x'}',ir-:ash
Irri tioII ^+ __ ':ice FROM TO MATERIAL +� EMPr:ACEMENr METHOD&AMOUrJT Supply Well: mr_ O ft ft eep-Tc (� b d
M,-itoring Recovery ? () ( _ ft ft i 0. -�
Injection Well: -
ft. ft.
Aquifer Recharge �Grotpi�vwater.RemMatiolr.r, s,,_ _
y }
r_IS.. ... ..� . ,: .�.•� ... ''. a F ' � o�f`'v.'--b.^= .,. d.:T""F. �vv!F�S�.r.rt'• �'.(i..t�"�,
Aquifer Storage and Recovery �$fllinity Barrier"°`-�•`',�L� FROM TO MATERIAL EMPLACEMENT METHOD
It. fL
Aquifer Test 13Stormwater Drainage
Experimental Technology Subsidence Control 1t• tt
Geothermal(Closed Loop) Tracer
FROM TO DES ON rro turdn soW k etc-)n V
Geothermal eatin Coolie Return) Other(explain under#21 Remarks ® ft.
4.Date Well(s)Completed. a Well ID# ��. R (�ft
5a..Well Locations ,, _ \6,o
Facility/Owner Name
�� 1 L Facility
�lD#(ifopplicable) ft it.
a0,•\ yV aCL T� � b ; It. ft
Phys'caI Addrrm,City,and Zip �j G (� ft . %
�; piY�."""v\ ✓Yti -1 ✓ 1.�1 ea l`3t'i� 2R}f7`'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal egrees:
(if well field,one lat/long is aufHcient) / / 22.Certification:
N ° 3 \1 w
6.Is(are)the well(s)�rmanent or Temporary Signature of Certified well Contractor Date
/ By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or O with 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
If this is a repair.fill out(mown well construction information and erpfain the nature of the copy of this record has beenprovided to the well owner.
repair under#I21 remarks section or on the back of this form
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.
dolled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: b (1) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100) construction to the following: ,
10.Static water level below top of casing: , (ft.) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniectlon Wells: In addition to sending the form to the address in 24a
c�--�,�..� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
li the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1't�� Amoant: t 2 a completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016