GW1--03038_Well Construction - GW1_20230310

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only.
1.We Contractor Information:
5' 1, .3-
FROM TO DESCRIPnON
' Well Contractor Name
A ��
tt. ft
NC Well Contractor Certification Number �.• _
C FROM TTO• D cTH'IC.KKNESSS� MATERIAL
Company Name E.7 ft. p 0 H' (31 V 1 C-
2.Well Construction Permit#: A a` co ` o� b v FROM ^TO DIAMETER THICKNESS I MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft % in.
3.Well Use(check well use): B' It. in.
[Industrial/Commercial
r Supply WeD: '.FROM TO DIAME'M SLOTS= THICKNESS MATERIAL
icultural [3M pal/PubIic ft. ft in.
thermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. In.
13Residential Water Supply(shared)'on FROM TO I MATERW I EMPLACEMENI'METHOD&.AMOUNT
Non-Water Supply Well: 1 :. i `�r" O tt ZO tt $ t:
Monitoring Recovery `:" ft ft.
i
Injection Well: 9 ft. . ft
Aquifer Recharge Ground a mediation
Aquifer Storage and Recovery [3Sativntt)j;Badieri
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stomtwater DtaiQ6 L
Experimental Technology 13Subsidence Control ft. ft
Geothermal(Closed Loop) 13Tracet
Geothermal eatin Coolieg Return Other lain under#21 Remarks FROM TO DEscR<prl0 color L.raa so0t—k eta
p fr' ft.
4.Date Well(s)Completed: ` r 0 Well ID# B' 1 U IL
5a.Well Location: S Z1N' 5,; `L
rt 4 ' ft =
Facility/Owner a Facility ID#(if applicable) ft ft
—To —�A 0`&.pjh Vp�y\A S f fL %
Physical Address,City,and Zip ft. ft
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one labbng is sufficient) a , 22.Certification:
6.Is(are)the wells) Pe rmanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cer that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or o tify with ISA NCAC 02C.0100 or 1JA NCAC 02C.0100 Well Construction Standards"and that a
Ifthis is a repair,f l out known well construction injarmation and explain the nature of the ropy of this record has been provided to the well owner.
repair under#21 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.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 00 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2®1001 construction to the following:
10.Static water level below top of casing: 1 A) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail 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
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 WELL •NLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Sanoiv&Iniection Wells: In 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: completion of well constructions 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