GW1-2021-00718_Well Construction - GW1_20210322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1�Wj�elll Contractor Information: 1
1-r11=1� AM �=�W i' 14.WA 7ANES
FROM TO DMiclarflON
Well Conui ctor Name
n. H.
W VJ C- CA ,:5G 3 n. I ft.
NCWell Conlmcmr Ccnificmion Numher 15.OUTER CASING(for multi-cased wells)OR LINER(if a BMille)
FROM TO DNh1EfER THICKNESS M1IATERLIL
ft. of n. 9_'5 in
Company Name _ 16.INNER CASING OR TURING( c S N-loo )
2.Well Construction Permit q:�/t�'1�1r�[�IYYI �� FROJI TODIAMETER rHICRNr_ss AUTERIAL
lJ'sr nil npplienblc yell rmrvnrrrinn permits ire.UIC.Crn nrrr.Store.Vnrl....re.arc.) in
3.Well Use(check well use):
Water Supply Well: 17.SCREEN
PPY FRO\I TO DIAM1ff:I'ER SLOT SIZE TFHCIC.YE55 M1IATERLkL
Agricultural QMunicipaVPublic ft. ft. in,
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. is
IndustriaUCommercial Residential Water Supply(shared) 111.GROUT
Irioatlon FRO\I TO MATERIAL ` E'1IP1-AC'E\IF.I-r MEr110D�&A�SIOUNT
Non-Water Supply Well: (�r n. t ft. BIZ Q + — —lJU 5
Monitoring Recovery ft. ft.
Injection Well: R- n-
AquiferRecharge ©Groundwater Remediation
19.SANIYGRAVEL PACK(if a licahlel
Aquifer Storage and Recovery QSaliniry Barrier FROM TO suTERUL EMPLACES ENT MErnoD
Aquifer Test QStorrwater Drainage
Experimental Technology QSubsidence Control n. h.
Geothermal(Closed Loop) QTmcer 20.DRILLING LOG(attach additional sheets if necessary)
FltO\I TO DESCRIPTION Js 'Mrdam..saiYmrk o, run siu•arc)
Geothermal(Heating/Cooling Return) Other(explain under tk21 Remarks) h. t h. 7
4.Date Well(s)Completed: — -Isl — Well IDtlW.,2O�f'xyY�tj LA I it' " ,t n. S>A()dp
fl. It. n) e-
5a.Well Location: -
t
Facflio,0rner Name Facila,IDN(ifapplkable)
IT. n. \101
Physical Address.City.and tip
(�h �zbKCP- 414 D5P41,] 9WL� 21-REMARKS
Count, Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
of well field,otre Winne is sufficient) 22.Certification:
n �7e1
N W y— I
6.Want the well(s){7oPermanent or QTemporary +11P"5A'21NCAC
f Certified Well Contractor Dare
TTTT This form I herh, certify rho,the o,11W mars hrrml7.Is this a repair to anexisting well: QYes or �/1(No /12C.0100 or 15A NCAC 02C.02IX1 Well Cnnsrnrrnnn Stood..ds and tlau n
If this is a rr,,ow.fill oar knonn..ell rnn,romrian it f rrnmrinn hod egrinin rLr....tore rif the c'rpy of dtis record has hear provided so the well under.
repair under#21 rerourk.s section or on the fork o rrhk f on.
23.Site diagram or additional well details:
S.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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
t
9.Total well depth below land surface: 36Lu (ft-) 24a• For All Wells• Submit this form within 30 days of completion of well
For otdriplr velLs liv nil deprhs if differ w feovnple-3(i2oo'and 2(.Intel construction to the following:
10.Static water level below top of casing: z (ft.) Division of Water Resources,Information Processing Unit,
1f a nrer Ievel is nhnre casing.use", 1617 Mail Service Center,Raleigh.NC 27699-1617
11.Borehole diameter: i � (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24u
JJ above, also submit one copy of this form within 30 days of completion of well
12-Well construction cable.
d method: F41�Z I �1� 1Z conswction to the following:
1 i.c.auger.mmn•.cable.direct push etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: lAr 1636 Mail Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm) 11r�. Method of test: Yt i l Z 24c.For Water SunDly & Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinrection eAw:W J Amount completion of well construction to the county health department of the county
where constructed.
Form GW-1 Nunh Carolina Department of Envimnmened Qualitc-Division of Water Resources Revised 111 2016