GW1-2021-01103_Well Construction - GW1_20210322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
l \son 1la WATER ZONES
FROM TO I DFSCRWHON
Well CoWoctm Nance
NC-WC- y303'� n. R
YC\Yell Contractor Certification Number 15.OUTER CASING(for multiaawd weft)OR LINER fda
)
an Ayl r3ztm L71G T S 1AL
7
Company Nance 16.INNER CASING OR TUBING( rimed-1 1
m
2.Well Construction Permit#- FROM M mAa -rER TIBCRVEffi AfATERI.D.
Lisr all app/irnb/e urll cormmcriar prnrdrz(i.e.UIC.Crumr.Store.Yarfaoce.etc.) R- Fl- to
3.Well Use(check well use):
Water Su 1 Well: 17.SCREEN
PP Y FRO31 I TO DIAMETER I SLOT SIZE T®CIrNESS M Tegx V
Agricultural QMunicipal/Public n. R
Geothermal(HeminJCooling Supply) VResidential Water Supply(single) R R he
Industrial/Commereial QResidential Water Supply(shared) I&GROUT
Irrigation FRONI 70 JUTERLV. E3WIAC'E3613T AfEfiIOD&AMOUNT
Non-Water Supply Well:
Monitoring ORecovery R. R
lnjection Wen: R R
Aquifer Recharge Groundwater Remediotion
19.SAMNG&1VEL PACK
Aquifer Storage and Recovery ❑Salinity Barrier FROM 7D 31ATERINI, E3�L3L'F.61EMr 3fE1HOD
Aquifer Test DStormwater Drainage
Fxperimental Technology DSubsidence Control R. R
Geothermal(Closed Loop) DTracer A DRILLING LOG)attach additimd drets kruesessaut
Geothermal(Heating/Cooling Return) F10ther(explain under#21 Remarks) no%l To R. t ILngc-Rmr7av kdw.awa.rs�v.wt ssa.ac)
Pri
4.Date Well(s)Completed:a—p15—aj Well ID# R. 1 R
—Sa. Location:oocation: t f h. R. f
Douq Ill(fi`Z
Facility rName Ftsciliry IDF(if applicable) ft. ft.
IND L-3p,4 On,m Iba IZ13 L,)Agri e MV-
Physical Addmsv.City.and Zip n. n. _.�'•
21.REMARKS
courax Parcel Identification No.(PIN)
Sb.latitude and longitude in degrees/minutes/seconds or tiedmal degrees: - �•
(if%fell held.one Lacdong is sufficient) 22.Certification: \
N W a —o —o`Zf
6.Ware)the wen(s)MPermanent or DTemporary Date r� um of Ceni td\Nell Controcnor
Bs si ring this fomr.l hereby rerfif.,rbar the nrllls)o.(were)eon oruoed in...dnnre
7.Is this a repair to an existing well: DYes or O(No with SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Cnnsrenctirn Sr a Lards ion I thin n
If rhis is n retniv Ill ow lmm..r..ell rnramarion infnnnminn and ecp/ain Orr nonce nJdre ]'ojrbiz record has bear provided m rise urll owner.
repair render X21 remarb senian or rm the Inc,of rhis fnnn.
23.Site diagram or additional well demBs:
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
sweion�nly I GW-1 is needed. ladicate TOTAL NUMBER of wens conslntcucgi details. You may also attach additional pages if necessary
Zg.' SUBMITTAL INSTRUCTIONS
9. Qr t
tal avell depth helow land surface: U�0 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
Fnnnahiple nrlls(ist nll depthr ifdifferem lerample-3at�INI'ard Jr(,i/lHl� construction to the following:
10.Static water level below top of casing: L46
ML) Division of Water Resources,Information Processing Unit,
If rmrer let el is above easing.use-+- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Lp (in,-)) cy' .,,, 24b.For Iniection Wens: In ackktion to sending the form to the address in 24a
12.Well construction method: Y'E I R 1\0 L MrRL� above•also submit one copy of this form within 30 days of completion of well
cortstmction to the following:
(i.e.au_ea,rotary.cable.dinect push etc.) T
Divadim of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: AA 1636 Man Service Center,Raleigh,NC 27699.1636
132.Yield(gpm) I Q Method of test:YSI LZ 24a For Water Supply&Injection Wells: In addition to sending the form to
L&Pa 'Z the alldress(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount:y'� completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Depanmem of Envimnrremal Quality-Division of Water Rezources Revised 2-'-2016