GW1-2021-00724_Well Construction - GW1_20210322

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER%ONES
FRO\I TO DESCRD'RON
Well Contact.,Nu me
n- I n.
W( 4t�t� *- n. I It.
NC Well Convict.,
fCen(ificcaie.Number T 15.OUTER CASING(for multi used wNh)OR LINER(if a ReaWe)
1 11 CA" J,,, 1 1 n a Inc, FROM IL TOR' t n. DLaS1EfCER m. TB1ClI-uN�EU SL\TERlIAL
Company Name U 1 llpC a7 l pc c.
16.INNER CASING OR TUBING( emherenal closed-lao )
2-Well Construction Permit#: FRoaI ill DIA�4-fER T1i1CIN1655 �;�RL
L'sr aft applicable urlt n Per mit pennirs li.r.UIC.C'nunrr.Suer.Vnriuner,co-,)
3.Well Use(check well use):
Water Supply Well: 17.SCREEN
PPS FROM TO DINUM11 SLOTSIZE TRICKNLSS I h1ATERWL
Agricultural QMunicipaVPublic [t. ft. I.
Geohermai(Heating/Crwline Supply) Residential Water Supply(single) R n, I.
InduslrialiCommercial NflResidential Water Supply(shared) 18.GROUT
]rrioalion FROM TO SIAMRIAL E.IIPLACEM EN-rN IiOD B AMOL'TT
Non-Water Supply Well: O n- a D- Q -5EQVAQ
_
Monitoring. ORecovery ft. f6
Injection Well:
ft. ft.
Ayuifer Recharge ©Groundwater Remedialion
19.SAND/GRAVEL PACK(if a licahle)
Aquifer Slorruee and Recovery DSaluuly Barnet FROM I TO SfATER1AL E\IPLACEIILW METHOD
Aquifer Test DStormw'ater Dminage n. D.
Experimental Technology DSubxidence Control ft. n.
Geothermal(Closed Loop) ©Tracer 20.DRILLING LOG launch addiBaoal sheets B )
G m FROM TO DMCR"ON(mla,herd s,sailhok1. le,ate)
eotheal(Heating/Cooling Return) (explain under#21 Remarks) n. t R
4.Date Wells)Completed: Well ID# ft. r n-
IL n.
Sa.Well Location:
Mklz w.)1jel-,teaA n- it.
Faciluvowner N:une Facihn'ID#(if applicable) ft.
aG'1'1 �} \U owl W e5V 11P y� �8U0\} It. n.
Physical Address. ily.and zip
21.REMARKS
Parcel Identification No.(PIN) My
Counn
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field. r.Iaulong is.sufficient) 22.Certification:
N IV
6.Istare)the well(s)7Y(Permanent or 0'Cempnrary Sr azure of Cenificd well Cummnm - Date
T� B signing.his 1.....I hrrelo renifr rhm the uz1B.d ... hi rel,m+mnrrwd in ucrnrrinnrs
7.15 this a repair to an existing well: ©Yes or/�f{No virh 1 iA A'CAC 02C.0100 ar 15A NCAC 02C.0200 Nell Consro,ori..i Srmrdrrrds and rhar a
Ifrhis is a repair.flit out Al . ....ell enrrsmm6on inf+mrrnrimunr�e,pla In the noun.nJrhr ('OP`''f rho record has been provided to rhr .rrrll nurser.
rr/wo lad,,=11 remn,#s sren.l ar nn for I.,rk r f this n,es,, 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Odty (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
Farvnubiple yells list all Aeprlu ifdg ra,r(......file.3(4.2n0'and 2C.100') construction to the followin_e:
10.Static seater level below top of using: Lill) (D.) Division of Water Resources,Information Processing Unit,
Ifo nrrr 6•rr/o,n)n...rasing.ose 1617 Mail Service Center,Raleigh.NC 27699-1617
11.Borehole diameter: 0 (in.) 24b. For Infection Wells: In addition to sendine 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: Al Z construction to the following:
1 i.e.auger,mu cry-cable.direct push cte.l
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 OL Method of test: A,,IZ 24c.For Water Supply & Infection Wells: In addition to sending the fun.. to
^',,'Q-�1 - the address(es) above. also submit one copy of this form within 30 days of
136.Disinfection type:�P Amount: completion of well construction to the county health department of the county
where constructed.
Form G W-I North Carolina Dcpannwnt of Lneironmotual Quality-Division of Wa(e,Resources Revl,cd 1 21 201 b