GW1-2021-01107_Well Construction - GW1_20210322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
SD AN�%0 U) L 50in 14.%VATER ZONES
Well Canuactor Name FROM FIL TO Matt ]oN
NCyJ 1^_ LM3 ft. ft
ppNC Well Contractor Certification Number 11 OUTER CASING(for u dti-anrd wells)OR LINER fda )
FR01311 ft 1O I ft- mAMEM THIChN nuTFRIAL
Cooipa%Name 0 5b a5 V G
I6.INNER CASING ORTUBING elasM4 )
2.Well Construction Permit#: t)Jrg 13 I PRohl 1 ro -p I MATERIAL
tist all applicable v ell ea ururn.t p rudi;6.e.UIC,Canh'.St w.Vari u,.lie) ft- ft- In.
3.Well Use(check well used: n rL o
Water Supply Well: 17.SCREEN
FROM TO DLURTER I SLOTSITE MCC ESSSS b1ATERIAI.
Agricultural Municipal/Public n, fL I.Geothrnnal(Heating/Curling Supply) AResidential
Residential Water Supply(single) t. R
IndustriaVCommetcial Water Supply(shared) Ill.GROUT
hrieation FROM M h1ATEsIA1, n(PLACramrr bfElnon a AAIOM7
Non-Water Supply Well:
Monitoring Recovery ft. ft.
bdectlon Well: R fL
Aquifer Recharge E]Groundwnter Remedidion 19.SANINGRAVEL PACK fd
Aquifer Storage and Recovery QSdinity Banner FROM ro auTTsul. FaR1.xCEMl2iT)fEllioD
Aquifer Tat OSumnwater Drainage rt- R
:)Experimental Technology QSubsiderRe Control
Geothermal(Closed Liasp) QTmcer 2aDRILLING LOG(attach adillboaai sheen if )
Geothermal(Heating/Coning Return) Other(explain under#21 Remarks) FROM TD t DrsL7�no,N hr.r.t...u1.� t �)
ft. R
a.Date Well(5)Completed:3-I l-al Well Wei)01 o31 �vl ft 75 pm
Sa.Well Location: 40 ft
L-6w m i E
FacilityiOwrcr Name facility 09(if applimble) ft' R.
3c234 Lk ', nd;n G 4a' liZc ToOI n h ft '
Physical Addtes,-City,and Zip R ft �1N
lu 51 yl q n 21.REMARKS
Cauuy Pucel ideuilorion No.(PIN)
Sb.Latitude and longitude in degreesfminntesfseconds or decimal degrees:
(if well field one Iat lone is sulfmiem) 22.C i cation:
awAre,e, ��..
��,,..,,,,,�(( ® 3--11- ,21
6.Iii(are)the well(s),oPernent or ©Temporary Si_ fCntifted Well Caotraaar Dore
//�� By signing this fomr I hereby cernft that he urlllso wins Fearer rnus n wd in ncmrdatre
7.Is this a repair to an existin well: ©Yes or No uilh 15A NCAC 02C.0100 nr 15A NCAC 02C.0200 Well Connnvtan Slandnrds and that a
ifdris is a repair.fill nut knnun ue0 raven ninn infnnnarinn a esptain the rarae of the copy of this record has been provided in ihr uell ouwer.
repair under F21 reauni,section or nn the beck orthis fomr.
23.Site diagram or additional well details:
&For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the bad of this page to provide additional well site details or well
conswctiOn d Ind,only I GW-1 is needed- TOTAL NUMBER of wells c�-swaion details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
((��t
9.Total well depth below land so rface: I lU (ft-) 24a. For An Wells: Submit this form within 30 days of completion of well
Fannaltiple uMs lie all depthr ifdfBerem(evvnpfe--3@100'and 2@101T) construction to the following:
10.Static water level below top of casing:A)b (ft) Division of Water Resources,Information Processing Unit,
If na/er kvrl is abase rasing.eve-a" 1617 Man Service Center,Raleigh.NC 27699-1617
11.Borehole diameter. (9 (im) 24b.For Infection Wens: In addition to sending the form to the address in 24a
n above.also submit one copy of this form within 30 days of completion of well
12.Wen construction method: conswctim to the following:
(m auger,rotary.cable.direct push dc.) 1 -
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
�s�.,
13a.Yield(gpm) r-T0 Method of test- Yt))` 24c.For Water Supply At Iniection Wens: In addition to sending the form to
2 the address(es) above, also submit one copy of this form within 30 days of
Elk Disinfection type: A e Amount: VO completion of well construction to the county health department of the county
where constnte ied.
Form GW-1 North Carolina Depuuoem of Environmental Qufin•-Division of Water Resources Revised b22.4016