GW1-2021-01209_Well Construction - GW1_20210323

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Weil Contractor Information:
,,�JI erH f,ab�' _ t'� 14.WATER ZONES
7Rh _, 1 ,. �� iROM m DESCRIPTION
Well Contractor
r�Name r ... J_. 7 - ^+ R SG fL /�-
a It.
NC Well Contractor Codification Nombsr 11,OUTER CASING Ifor mdtl<ird wNMJ OR LIVER
^';r'^�( m DIAMEIE¢ TRICKNi35 MATHRUL
��1r�f-9-rGf1/f7-� �1� (�--1'.i...l..,i.�_1 rT �- R R a.
Compaq• aN me 16.INNER CASIN73 Oil TUBBVCETER hermal
2.Well Construction Permit III:: J 2Z FROM TO DIAM THICINTSS MATiJUAL
listall ayplicaMle.11 macsnucnnn permits 0-e.UIC.Cmnnn•.Store Variance,elrl R. IL in
tL AL in
3.WellUse(check welluse):
17.SCREEN
Water Supply Well: FROST I To I DIAMETPR I SLOT SIZE I THICKNESS I MATERIAL
DAlpicultmal ipal/Public
OGeothcemal ❑M(Heating/Cooling Supply) evidential Water Supply(single) fL R It.
Dlndusmia/Commercial ❑Residential Water Supply(shared) IL GROUT
CEIrrigatim OWe11,> 100,000 GPD PROM TO I MATERIAL I Els; FMrM On&AMOUNT
Nora-Water Supply Well: d R' O R- 14wlee
IlMonitoring ❑Recovery h R
Injection Well: ft, rL
❑Aquifer Recharge DGmundwater Remediation
19.SAND/GRAVEL PACK if
DAquifer Storage and Recovery OSalinity Barrier FROM 1 TO I MATERIAL FJRMCTMENT METHOD
DAquifer Tmi DSmrmwata Drainage D- h
❑Expcnmenlal Technology OSubsidence Control ft. I R
DGeothermal(Closed Lap) OTmcer 20.DRILLING LOG(am tY addidool dareu 0
MOM TO DESCRIPTIONrare.a.ed.
ClGeothermal(Heatin Coolin Return) ft. R. d �'0) 001her(explain under#21 Remarks) l wvrxa fIL
`
4.Date Well(s)Completed:, Well IDk '1 R' Dt1 fL CIO
Sa.Well Location: O rt. G R. S M1
LA G R. n. C
Facility/Owner Name 1 Facility ID4(1'applicable) 0. ft.
lu� (�a.�tlec.kc J fL f.
Physical Address.City,and 7p ft. R
Fri,r=�i\ 21.REMARKS
Coady Parcel Identification No.(PM)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Ilfwcll ficid•orc IaUlong is suRcicnU 22.Certification: /�'J 9
N W' •7��1:'• �(
6.loose)the we0(s): errmnemt or OTemponry slgmtum o Cenifid <Ii c mr
By signutg thm/orm.1 hereby c erai,(v Nat the xell(s)SRr(Sere)roadracted ut accordance with
7.Is this a repair to an existing well: OYes or 8No 15.4 NCAC 02C.0100 or 13A NCAC 02C.0200 Well Construction Standards and that a rope
1/rhu is a repair.fill not known aril construction in/srmamm and explain the nature nJthe afthu record has been provided w the Sell owne,.
repair undo E21 mmarto section or on the Mach f thir(arm.
23.Site diagram or additional well details:
S.For Geoprobc(DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well coumuction info
constmction.only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled. 24.SUBMMAL INSTRUCTIONS
9.Total well depth below land surface: completion o!well 30 d within
1 GW- w n a, (R') Submit this s eon
For multiple Sri/s list all depths iy'diBerent/exam 1 @2�nd 2@100') Y p per the following:
10.Static water level below top of using: d (!L) 24a. For AD Wells: Original form to Division of Water Resources (DWR),
!fearer level u ahawca4ng.utr"-/' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: h (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
n r Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well LRmgrnelioe method: U\1'T-/if t/ 24c.For WRter Sn and Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,dkect pah ar.) county envtronmmal health I of the tounty where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Webs mroduciu¢aver 100.000 GPD:Copy to DWR,CCPCUA
y y Permit Program, 1611 MSC,Raleigh NC 27699-1611
13a.Yield(gpm) O Method of test:
13b.Disinfection type: Amount:
FormGW-I Nomh Camllna Depa tof Pnvimnrrenul(2mlity-Divisionof Water Resources Revved 6-6-2018