GW1-2021-00646_Well Construction - GW1_20210205

WELL CONSTRUCTION RECORD (GW-I) For Internal Use pith
1.Well Contractor Information:
To ,' 1E WATER ZONES
FROM I TO I DESCRIPr1O5
st eit C.,Vnav/orr�\ame
R
LII J I � '_ � IO fL QGi A= C(-tN P
NCWell Contractor Cemficanan\umber �6 R V fL I { ,;rtR �,FF1e Jn.
CASING (se FROM
OLTrEA CAS RI
_ OM TO DIAMETER THICKNESS M�A7TERIAL '~
C o'r: �rl✓I 1.1 �t Cite$+f 4ltlIL✓1 LCC FRS.H `7 t' L
Company
?ff v 1^/ 1L l.�7 1 16.INt�A CASBiGOIIYBBiNG atisi�ielr
2.Well Construction Permit X: :J W 7y 0 '�" �'"11I I / rRON TO DtaNETER THICKNESS MATERIAL
I,vail I!, LIC.C.anti.yYau-ba:orue-r:n, PL ft. is
3.Well Use(check well use): It IL
is
JA
er Supply Well: —v SCYEEN "x�itixK+-:-
FROM TO DIAMETER SLOT SIZE THICKNESS NATERIALT
icultural [3munic:pal Public OI ft. ^v R I I/ isSa+1 UG gL
othermal(Heating Coolme Supply) �Resldennti Water Supph (siFgle� i', fL R is
ustrial:Commercial ©Residential N'ater Supph(sharedL&GROUT
l
ladtlOn FItON TO SATERIAL ENPLACENEST MEEHODAANOVNT
-Water Supply Well:
onitoring Recosen M fL
ction Well:
R M1 :
uifer Recharge Groundwater Remedtatlon uiferStorageandRecoven �Saiimn BameruiferTest 13Stormwater Drainage R fLZ� tZperimental Technolog> Subsidence Control f- I R
othemal(Closed_oop l �Tzcer 20.DRtI,LIItG LAG iumbothermal(Heahna-Conan Return) Cnher(.xpIam under=21 Remarks: EaoN ro DESCRIPTION(wbr,IUNosvWrvck yq afel
4.Data Well(s)Completed: UZi Well ID# A R 1O ft. bye St_ }
5a.Well Location: to R. L O IL I
Nellie T pa,dle'
�-- Faclli"Owner Name FauL.:v'D=(if aPp LcabiN R R
I
�tnd�tOrT/Ccrcll + tZ79Z7 L
Physical Address.Cirv.and Zi0 DL fL
LHrvt},Acy—
parsai identification No (Pl\) u51 S end F+V �u/e 4(r G4•"iYNPr S.L Pa,kel
5b.Latitude and longitude in degrees/minuteaiseconds or decimal degrees: J'fl Yr CkP r A I IOG ''r♦'
(Ewell fell one iavione"sutfidentl 2.Certification:
( 2
2— Li1 1 JL 51 '4 11 W'
/�-✓ �'� I Ir Zrz
6.Is(are)the well(s),Permauent or Qiemporan are
�E Sierxrw< enifi ell nnaror D
� gere+a:nerur,ad vi arcnrdance
7.IS this a repair to an existing well: ales Or ONO E� > aC AC 02C G!IG i ,C4C 02C 9206 IVe((Cnns(rarlion.SrandarQs and lhN a
IJ+ha ira repair fi(oui Armwn rce((rnnsnuraan it/nrma r .+w c.p'ain lnL.evr �rero a .¢s neon pro:i,.e6+o+he ve!(nwnec
repair under a21 remark ern.,. the hrrk + F/arm �O X 5
ZQ 2i.Site diagram or additional well details:
8.For Geoprobe/DPr or Closed-Loop Geothermal Wells hatits5liip o,me, use the back of this page to provide additional well site details or well
construction,ODIN 1 Gv. : 'a needed. IndicateOTAL NUMB(�� �6`gCessln`orst ciion details. You ma}also anach additional pages if necess ury
drilled'. �"eC/lOn SIC py INSTRUCTIONS
9.Total well depth below land surface: a f- lft.l 24a. For All Wells: Sucmit :his forth within 30 days of completion of well
I ar mi, iple mellr lvt a 1 depths:]dam ere(eram,o(e-J2.700 and]Z.10a')
construcn on to the follow na
10.Static water level below rep of casing: `l (ft.i Disision of Water Resources.Information Processing Uniq
1Jwmer level is a—e ras:ng.:.•e-' 1617 Nail Senice Center,Raleigh,NC 27699.1617
11.Borehole diametae (in.;: 24b. For Injection Wells: :n addition to sending the form to me address in 24a
abo,e, also submit one cep) of iris form within 30 da.s of completion of well
12.Well construction method: Hr,42( constn:ction to the`ollowme
(i e.augm ram).cable,direct push etc J
Disision of Water Resources,Underground Injection Control Program,
[13a.
WATER SLTPPLY WELLS ONLY: 1636 Nail Santee Center,Raleigh,NC 27699-1636
Yield(gpm) t/2 Method of test:�AS�un.p i 24c. For Water Supph,& Injection Wells; In addition to sending the form to
the address(es) above. also submit one cop} of:his form within 30 days of
Disinfection type: m 1 ( .[.mount: 1• S e L compleeon of well mns;mction to the count} health department of the count)
where constructed.
Form GW-I North Carolina Departmeni of Enironmanial Qualm-Division of Wamr Resources Raised 2-22-2016