GW1-2021-00812_Well Construction - GW1_20210215

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
rei It,( -TRCC 14WATERZONPS
IRON I TO hESCFurrms
well Contactor Name It. 76 ft. f eyam
a ?L-s_A fL R
NC Well Contactor Certification Number IS.OUTER CASING fw roam-wed wells)OA IdNER hk
C C FROM TO DIAMETER TRICKNPS4 MATeRW.
r l I ft. b 3 ft. - I- I v
Conway Name 16.INNER CASING OR TURING
2.Well Construction Permit d:�q� FROM To DIAM7d@sed4
TmCIDILut all applicable wellpermits(i.e.UIC.Caun)•.Sato Variance,era) ft.
3.Well Use(check well use):
Waver Su Well: I7.SCREEN
PMY 17.SFluskI ro I DUMkTEa I SLOT SITE I TRtcENEss I MATF•rar.
OAgricdlural OMunicipal/Public (7 ft• L i` I�SZ .-(/
OGeothcrmal(Heating/Cooling Supply) f�dential Water Supply(single) R R. la
Olndusb=I/Commercial ❑Rc idmUd Wait Supply(shared) IRS
ClInnigntim OWells>100000 GPD ;19.SANEDIGRAVVEL
MATERIAL EM!!ACEMENT A,AMOUNT
Nos-Water Supply Well: �' v C
OMonitoring ORecovery
Injection Well:OAquifer Recharge OGroundwater Re mediationK❑Aquifer Storage and Recovery OSalinity Bartier MATFAIAI. EMPLACEMNTMLTIIOD
OAquife Test OStormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG att,eh addideW skeet,if aeeew
OGeothe mad(Heatin Cooling Return) OOther(explain under#21 Remarks) raoM ro DFsaumoN al.r.braaus.mvaea eu.
6 m 3 fL
4.Date Wells)Completed: L Well ID# "• do
R. G,
5a.Well Location:
It. fL
r
Facility/OwnerNamc, II J F Try�°plif applicable) ft. ft.
yOL�� C Lt n. IL
Physkal Addseas,City,and Zip 2 R
I f.Gn✓.'{I�J 17.REMARKS
caunry lT Parcelmentitutian Na.(PIN) 0! e 1 T.Jp .S c
5b.Latitude and longitude is degrees/minutes/seconds or QecimN�egiesss
(dwell fid4 om ht/Wg u suRckm) - 22.Certification:
N _ 1_. W e L
6.Is(are)the well(s): f3Pfrmasent or OTempur1rj 1
6 Sipmure ofCertiOcd Well Contractor Duc
- '�' � Sysignatp lhirfwm.l hereby cen�thai the welllsl has(wrre)Mrutrrctd in aeenrdaMr with
7.Is this a repair to so existing wed: ❑Yes ;pQ,t'.dNq. C Ci;I I5A NCAC 02C.6100 or ISA NCAC 02C.0100 Well Construction Standards and that a copy
1f1h.a a repair.Ill..Am.uell raniOLrllna uq/i rma t,oil aad ea�dvs Ue Mare t fthe offka record has heenprae ded In the tort/.an,
repair under h21 remarks seraar nr an the bark fthisl^rnr.
23.Site diagram Or additional well details:
8.For Geeprobe/DPT or Closed-Loop Geothermal Weds having the same You my use the back of this page to provide additional well construction info
construction,only I OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMTTTAL LNSTRUCFIONS
9,Total well depth below land surface: 7 (B') Submit this GW-1 within 30 dap of well completion per the fallowing:
Far multiple urlh list all depths ifdp rent(example-3C*200'and 2(g10 r)
10.Static water level below top of casing: L' (D) Ms. For All Weds: Original forth to Division of Water Resourccs (DWR),
Ifusster le,rl tr.Moe raring.me"-II Information Processing Unit, 1617 MSC,Raleigh.NC 27699-1617
11.Borehole diameter: W (in.) 24b.For loiection Weds: Copy to DWR, Underground Injection Control(IUC)
(� Program,1636 MSC,Raleigh,NC 27699-1636
I Wed construction method: ' `U+C'C'�
(i.c.au rotary,wbk,d'uxd h,era.) 24c.For Water Su asd Lon Geothermal Return Wells:Copy to the
ecr, Pa count'environmental hnith t o e county where installed
FOR WATER SUPPLY WELLS ONLY: r/� 24d.For Water Wells Droduc s over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) a 5-IL��,� Method of test: 6( Pcmtit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount: I L b
Fran C W-1 North Carolina Department of Envirooaental Quality-Deision of Water Resuarces Revised 662018