GW1--05641_Well Construction - GW1_20230831

WELL CONSTRUCTION RECORD(GW-1] For Internal Use Only
1.Well Contractor Information:
• Well Contractor 0!� DEScRIPIlON
- 16-a -Q--- ,�
- - A-o - 9
NC Well Contractor Certification Number F.• -. - -'- - ,
6Ze,6�oen ( �.ICU:eAn "Ord l Ian I n C . PR° © :10+N ..:� :
® 1 t 1 ft. t Ain. DI' P NIC
Company N� '' r ,'f R
2.Well Construction Permit#: FROM . I)Cik'•I DI V A Y:I{II W./5k111. MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. t I in. —
3.Well Use(check well use): ft ft. I in' —
Water Supply WeII: ��III 0 rl r:i1 Y.A:�`Y to IlY Y•:,M IDY I(N.4�I>$.
!;,.vY•A lisism
DAgricultural E3M:3104WPublic it. fi. in. —
I Geothermal(Heating/Cooling Supply) tial Water Supply(single) ft. ft. to.
E Industrial/Commercial DResidential Water Supply(shared) -. r 7
M1 f} r fhur y'F-�.t1..
•Irrigation FROM o B wY:Arc,\��A;IO�T/I:nSI140116II1$:{gll,.TNto V:rl,.
Noft. ft. s • S ,Non-Water Supply Well: - .. Ip 020 L© r� i� �j� °
■Monitoring DRecovety ft. ft. 1r EINrgffllEMIIIIII
Injection Well: ft, ft. 1111111111111
•Aquifer Recharge DGmtmdwater Remediation
ti I Aquifer Storage and Recovery DSalinity Barrier r. 2•111•1111011111111wrimvjoiiiilii■A;I w\. sl a r r I r r;cu l
■ Aquifer Test DStoimwater Drainage . • ft' ft.
■Experimental Technology DSubsidence Control ft.
• Geothermal(Closed Loop) - DTiacaQMIIIIIII r"•` "< „-'
1 Geothenal II_Coolin Return di Other '.•,lain under#21 Remarks — I A '4 I' 1 f. rnr•r-r_II a„ , m-�n�
4.Date Well(s)Completed: b I 1 SIR
a 3 Well ID# Ar l a�c 4 O ; C` • '�
11 A �
5a.Well Location: . • av m f- t_ r- 0 - 'f✓\
Facility/ Name Facility lD#(if applicable) • ft. I -
SI"6 ( ac- hi am., . �a:,lc.,;�,� We .
Physical Address,City,sad Zip ‘
ifk V-\C.E)"Vv..._V:e OkID () A aN a 4.\ : .. , : . 7:,,--..,,,,: , .-:.. .-,-..,..,,,,,..-..„7,...-„,...,-„,-,---,..3,,,,,,,y,,,,,,,,,,
County Pastel Identification No.(MN)
MINIIIIIIIIIIIIIII
IMM
5b.Latitude and longitude In degrees/minutes/seconds or decimal degree.:(dwell field,field,one lat/long is sufficient) . . _ 22.C i cation: i
(� ;Info. aU~n Prr.;e a�;t' r,.
3 5° 31/ ?, 1 _N g ,`as -3 W 1, ' I DWOMO,a `o a0 a3
6.Is(are)the well(s) rmanent or DTemporary Signature f ' ell Contractor;; -
By signing is fun n,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to en existing well: Dyes or o • with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill out koown well construction it fonsation and explain the nation of the son'ofthis maid 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: OW 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd different(example-3@200'and 2(41001 construction to the following: I, i
10.Static water level below top of casing: - (f t.) Division of Water Resources,urces,Information Processing Unit,
'limier level is above casing use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: NO 246.For Injection Wells: In adddition to sending the formto the address in 24a
fI - above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: l4—o construction to the following 1
(i.e,auger,m>ary,cable,direct push,etc.) , -
D ivision of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: - 1636 Mail Service Center,Raleigh,NC 27699-1636 -
132.Yield(gem) Method of teat: S
24c.For Water SuoDIv&Inject• ion Wells: In addition to sending the form to
A
the address(es) above, also subniit one copy of this fora within 30 days of
13b.Disinfection type: 'N 1 Amount 1,to O 7 ' completion constructed. construction to the county health department of the county
Form GW 1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016