GW1-2021-00930_Well Construction - GW1_20210305

V 12,L L CONSTRUCTIOlyy=r- l CORD-(GW-1) For Internal Use Only:
tall Contractor information:
14.WATER ZONES
—� FROM TO DESCRIPTION
:i�Il Contractto�or/IN1'amee ' ft. &44's ft &0 00A
_ or(4&) lV-J ft. fL
:ell Conn•actor Certification Number
p ,p 15.OUTER CASING far multi-cased wells OR LINER if a licable
UVI� CO M 1�4�11�lr' 19 i1 a FROM TO DIAtMETER THICKNESS MA't•t,RML
ft. I ft. in.
;..nr,•Name 16.INNER CASING OR TUBING(geothermal closed-loop)
:Consiruction Permit#: -7/ < FROM TO I)Wit ETER THICKNESS MATERIAL
n;yirdicnble well consbuctiatpermits( ounty,State, variance,etc.) 1 ft. I T Ct. !_°% in. �1�
ay Use:(check yell Ilse): U/
,3F pry Weil: 17.SCREEN
,. FROM TO DMMETER SLOT SIZE THICKNESS MATERIAL
!ral ❑hilunicipaVPublic ft ft. in.
(Heating/Cooling Supply) residential Water Supply(single) ft. ft in.
C 1' _.trial/Commercial ❑Residential Water Supply(shared) 16.GROUT
O_:t• tton ❑Wells> 100,000GPD FROM TO MATERIAL En M MPLACEENTMETHOD&AD40[NT
r Tt,t,=1 Supply Well: ft. 44 ft Mole i�1 fOl7CC� 4 �G .S
il..;:.!-3iing ❑Recovery 14 ft- DD tt. avicK G:ovt PUM14g
Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Ll Jl` Storage and Recovery ❑SaliniiyBarrier FROM TO MATERIAL EMPLACEMENTVVIETHOD
❑;-at!i er Test ❑Stormwster Drainage
0 ;;r eri,nental Technology ❑Subsidence Control ft. ft
❑tea+ib? -nat(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary
❑Gtode einial(Heating/Coohng Return) ❑Other(explain under#21 Remartcs) FRoiLl To DESCRIPTION(color,hardness,soil/rack e,grain size,etc.)
ft' 13 to tt.
�aal�zo
.a.,a,:e%✓ell(s)Completed: TbV '�'.'ell_ d G ft. /S`_vO it. Gi2at1
aid LUCailOn: ft. ft.
oft. ft. l a .i
ft. ft.
lirl!y11r0,a!!ter Name / I, t,,' Facility lD#(if applicagb�let)f1
�ve� �l ill Vetlllz" VVGli/ Zf'4d!r*
d`dresss,{City,and Zip ft. ft. .��
2i.I�ALARKS i7d�11�, �'. :—f•,��(,�'.t`i'll
Parcel Identification No.(PIN)
t :Wde and longitude in degrees/minutes/seconds or der-imad degrees:
M iiald,one fat/long is sufficient) �j�j yt 22.Certification: p
3 t�Ll, l �S N V O J 1 r �g� elv d 3
die well(s): -ova-y Signature ofC tified Well Contractor Date
nd
II
B y signing this farm,1 hereby certify that the wells)was(were)constructed in accordance with
-AO.- repair to an existing well: ❑y es o e 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
I-eoair,fill out kno!vn well construction information mid arplain the nature of the of this record has been provided to the well ouster.
:r W l renmrhs section or on the back o/'This form.
23.Site diagram or additional well details:
3• oprobe1DPT or Closed-/Loop I:'eotheri,Ia9 VV_lts having the same You may use the back of this page to provide additional well construction info
r;_3si!uction,only I G'vV-1 is needed. Indicate TOT.A-L hftNIBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessat.
24.SUBMITTAL INSTRUCTIONS
i'.:,`Sl-,yell depth below land surface: (ft.)
;salt pM wells list ail depths if different(example-3©200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
ff 24a. For All Wells: Original form to Division-of Water Resources (DWR),
3F:atfie vVatel level below top of casing: 0®� (it•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
e;maim level is above casing,use"+" p
i. :nt elaole diameter: (irr.) &.O Q 24b.For 1Ajection Wells: Copy to DWR,Underground Injection Control(NC)
Program,1636 MSC,Raleigh,NC 27699-1636
:-:tar construction method: SIB R � 'O _I"'tF"Y 24c.For Water Supply-and Open-Loop Geothermal Return Wells:Copy to the
,. .auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
>1'WATER SUPPLY'bVELLS ONLY: v -•_��_ _ _ _ 24•d.For Water Wells Producing over 100,000 GPID: Copy to DWR,CCPCUA
a r Permit Program,1611 MSC,Raleigh,NC 27699-1611
iphl UP-) &(). l.'!I.6:il,,,�fuo kcsi: �!
70% S u B hH ��� O Date Site Visited-.
G��ashifection type: Amount: