GW1-2021-00813_Well Construction - GW1_20210215

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
I.We/ll Contractor Information:
a�0 5H G�b f 10.WATER ZONES
..��cc-1 FRDM TO DfSCRIRIO�
Well Contractor Name M R
NC Well CoMractm Certification Nines 15.OUTER CASING for maWaaud wear OR 1.IIaPJT
FROM TO mAat*- TRICKNPSS MAnJ
�d
c� FL 1
Corgvny Namc n 16.INNER CASING OR TURING ekredA
2.Wall Construction Permit 0: /e y FROM ro DIAMETER TntcxNEss auTEatAL
Lire all applicable xrll rnnsmu<nan pmnits/i.e.U/C.Gnm9'.Stale. Variance.<m)
R R to
fL IL n
J.Well Use(check well use):
17.SCREEN
Wafer Supply Well: FROM ro DIAMETER SLOT SITE 7RICKNE55 MATERIAL
❑Agricultural 0%4=icipaVPubhc I h `C FrC
OGcotherrnel(Heating/Cooling Supply) Offesidential Water Supply(single) fL ft. la.
Dlndumiai/Commercial ❑Residential Water Supply(shared) IL GROUT
Dlmi Lion DWells>100,000 GPD FtaOM ro MATERIAL. EMPLACEMVfr MLTRODa AMWnr
Noo-Water Supply Well: D' O R' 2 G t!
❑Monitoring DRecovery R R
Injection WeB: R tl
DAquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK irabM
DAquifer Storage and Recovery OSalinily Barrier FRod ro MATERW. FMPLxCEMRaT ME1Rtm
DAquifer Test ❑Stonnwater Drainage R. I,❑Experimental Technology ❑Subsidence Control R. fL
DGeothennal(Closed Loop) OTraccr 20.DRILLING LOG tons addidead ab ft ifsecom
TftL
TU D6LRPrTON arW.hwanws wlarxk we
OGcothermal(Healin Coolie Return) DOther(explain under#21 Remarks) 3 d.
�1 G S 0°,-
d.Date Well(s)Comphted:a Li a I well IDO p�J ' C !iSo.Well Location: S'C D' SunFacility/Owner Name Facility IDa 1 applicable) RkWVt2 CT
D
Phio i<al Address,City,and Zip rL n.
tr P cAJ:l(4 21.REMARKS II
County Panel Identification No.(PIN) . CEr I 4rdes, ✓ h e
Sb.Latitude sod longitude in degrees/minules/sernnds or derimd degrees:
hfwell f Id,one Wiens is sutf,iem) 22.Certification:
N W
6.span)the well(s): rmaaept or OTem Di..porary _SigrmurT of Certified Wcll ootractor
_ Byngaing this/am.I herebyeerdfv that the xrthri)tuns(wrrc)romvarted in acewdance%ilk
7.Is this a repair to an existing well: DYes or GNe 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standard,and that o rope
Uthis b a repair,fill eat brown well rnmwco is orlbrmotum and eirplpn$e liampe of the q`ofdo,record har been provided a,the%ell owner
repair under s21 remanl section or on the back oJlhojorm. ; . tL%L R3 Site diagram or additional well details:
4 < 1-
S.For Geoprobe(DPT or Closed-Loop Geothermal Wells hav stale You rru'use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. indicate TOTAL NUMB L' wells --(add See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 14.SUBMITTAL INSTRUCTIONS
9.Total well depth below load surface. C Submit this GW-1 within 30 days of well completion per the following:
Fnr ma/aple xrlls list all depths iJd�erenr ferample-3Q2011'and10 0')
10.Static water level below lop of casing: (fL) 24a. For Ali Wells: Original form to Division of Water Resources (DWR),
IJxotrr level a abnre rasing,are"-"1- Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Injection Wells:Copy to DWR, Underground Injection Control(IUC)
an� Progra , 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: m2dc.For Wares SuDp1Y and Opeo-V Geofhenpal Return Wells:Copy to the
(i.<.auger,mury,cable,direct pmlt eu.) county environmental health department o e county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR.CCPCUA
r�13a.Yield(gpm) Method of lest- m p Pm m it Progra ,1611 MSC,Raleigh,NC 27699-1611
I � f✓
13b.Disiaf"tion type: ( Arousal: L b
Faro GW-1 North Carolina Dtpancncraofltr iounrreont Quality-Divisionof Wstcr Resources Revisal 6-6-2018