GW1-2021-01105_Well Construction - GW1_20210322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
3AM&:5 t�AN;eI W I'�n 14.4VATE 2Or
FRO\( TOI DESCRIPTION
Well Contractor Name n. R.
W—WC. 4303 It ft. n.
SIC lixcw`well Comoaac�teo-rr Cmficauon Number PMOUFER CASING(for mW i-aC ed vrelb)OR LINER ff a ble)
11(C )[)r 1 �1 ( r TO OL1A4.�IERHICANESS SL\TERIALCLt.-. ZI 1� 1 ��C. n. 51 1 R. in. ` V
Company Name 16.INNER CASING OR TUBING( anal rlaee01-1 )
2.WeB Construction Permit#: 69 O all 4
FRONI TO ft.. METE DIAR TRICIC'SESN A MTERIAL
L'sr all applicable uz-0I rmts)runion pertainpertainsr'.e.///C,Cnnntr.State.Vtnnnre.glut '
R, a
n. ft. in.
3.WellUse(check well use):
17-SCREEN
Water Supply Well: FRONT TO DWII=R SLOTSIZE ITRCKNIYSS MATERIAL
Aericulmral Municipal/Public n. FL in•
ir�
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) R. R• in.
Industrial/Commereial QResidential Water Supply(shared) IR.GROAT
FRONI r0 NLSTERIAI. ESIPLACT:NIENT NRTDOD&AMOUNT
irri°ation
Non-Water Supply Well: t ft. R.
Monitorin° Recovery D. fL
injection Well: n. R.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK IBe ale)
Aquifer Storage and Recovery Salinity Barrier FRONT TO }IATERLSL EMIUCENIE- MMtOD
Aquifer Test DStoodwater Drainage R. R.
Experimental Technology QSubsidence Control R. n.
Geothermal(Closed Loop) [DTracer 20.DRILLING LOG(attach additional sheets B )
FRONT TO DFSCR�TION I�br.W.decs-roa'mrk t rx,nr.l
Geothermal(Hesiong/Conling Remm) Other(explain under#21 Remarks) n 1 R.
4.Date Wellfs)Completed:- 06-21 Well ID#64157ao-� t R• 1 n- SR t1
n. n.
Sa.Well Location: 10
g n. 3 n- '
r^S1�il�r4 MAR ;N
t 4,wncr Name", , Facility IDN(ifapilwid,10 n' n•
LET�r'[,5�(:�•l0(101. 1��IlE f�0� n. n.
Physical Addmss,City.:md Zip \
M AWM 1n619"1►1�l I B 21.REMARKS `� t
Comte Parcel ldemifica6on No.(PIN) til -
5b.Latitude and longitude in degreeslminutes/secnndx or decimal degrees:
(if well field one laflone is sufr,6,n0 22.Certification: ,.
N WC,M��O' roll
6.Isare the webs -
W(Permanent or Temporary
Sig lure of Certified Well Contm urr Date
. . r nndnnn
Br gyring This Jnrnt 1 herehr rears That the az/l(d nrer Iverel rnnvnmeA m r r
7.D this a repair to an eAstiug well: ©Yes or f��y[f No h I SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Conson torn Standm'ds nod shot u
!l out knmvr udl ronsrmai°n in onarino rhrd er 1 'n the nature rrfrhe rrrpc nJThis record has been pnn'ided to the yell owner.
IJ rbis is n relwir.fi f' P°'
re/nor under#21 remarks section or on the back Jdtis 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 in 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: I SUBMITTAL INSTRUCTIONS
� f
9.Total well depth below land surface: 3� IfL) 24a. For All Wells: Submit this form within 30 days of completion of well
Fonnuniple yens Iisndl depths iJdigment(e carnple-3C2n#)'smd 2toy100') construction to the following'
10.Static water level below top of casing: ,061 (ft.) Division of Water Resources,Information Processing Unit,
if eater/,It i,nlnn"r.ing.use,-' 1617 Mail Service Center,Raleigh.NC 27699-1617
11.Borehole diameter: Lb (in.) 24b.For Liection Wells: In addition to sending the food to the address in 24a
'�//fi ,,�� above. also submit one copy of this form within 30 days of completion of well
12.Well os cotruetion method: Q )1 construction to the following:
ox auger.merry,cable.direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm) I a Method of test: A I lZ 24c.For Water Supply & In Wells: In addition to sending the form to
-�
the addresses) above, also submit one copy of this food within 30 days of
13b.Disinfection type:J P11 s Amount: 36 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Depamorm of Eta iro nnenml Quality-Division of Water Resoumes Revised 2-22-2016