GW1-2021-01403_Well Construction - GW1_20210329

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
burn J-1—lC Oh S 14.WATERZONLS
Well Conpnnun Name Mot I To DFSCIiIMON
S n. h
?' X/ h h
NC Well Contractor Cenifi.tioo Ni rnber IS.OUTER CASING for maltl-tact web)OR LINER • Yk
I a h Frvn I L� r l C/� Moat TO D��R TRICKNM MATESUAL
h I IL IUD Ia.
ca�nrry .me 41
IL INNER CASING OR TUBING t1aaH
2.Well Construction Permit 0: FROM I 70 DIAMLIER TrICk1TSc MAT[rDAL
Lin all applicable well enmaucunn permits n.e.UIC.Count,Stare.Vamon,,,etc) n. R ia.
3.Well Use(check well use): h h in.
Water Supply Wen: 17.SCREEN
FROM TO DIAMEITR SLDr SrTE TIrICIDVEcc MATFJ rer
OAgricultural ❑MtmicipaVPublic h h lu
OGcothermal(Heating/Cooling Supply) idential Wafer Supply(single)
❑Industrial/Commercial OResidential Water Supply(shared) IL CRW7
ohnixistion OWelis>I0D,000 GPD sROM To I MATERIAr. i KhWN.ACOAHrr MCiNOD•Axto11M'
Noo-Water Supply Wen: 0 h 96 fl. , r�
OMonitoring ❑Recovery ft. J Ft
Injection Wen:
n. D.
OAquifer Recharge OGroundwater Remediation
H.SANWCRM PACK B
❑Aquifer Storage and Recovery OSalinity Barrier FROM err T
MATrAUAL rkarLACEMEvr MtmloD
❑Aquifer Test ❑Slormwater Drainage rL h
❑Experimrntal Technology ❑Subsidence Control n. n.
OGeothermal(Closed Loop) OTraccr 2L DRILLING LOG aWeh Additional sheenU
Drsewmon seer saaarss. eu.
OGeothermal(Hearin Conlin Realm) 0l3drer(explain undo 0 mom Fro, w1yend,21 Remarks)
v <i
4.Date Well(s)Completed:.3-.;�.�, a I WeI11D0 n• n• C G
Sa.Well Lacadon:
Facility/Owver Name 1 Fa:ility[Da tifapplicable) ft. ft.
it, lr-grf �l Farm P� rL ft.
Phy,iwalAddm&City,and zip tAl
ft.KS
County Panel Idenifiratiun Nu.(PIN) I t l
5b.Latitude and longitude in degreealmioutes/semnds or decimal degrees:
(ifwcll field.one ht/long is suRchno 22.Certification:
� N W
6.19(are)the wen(s): 4ernuoeat or OTemporary Sigmt ofCerlified WcllC r Doc
`/ By,orrderg thu form.l herebycerafvlhat the tie//(s)ruts(were)ro alive d in anardartt"k
7.Is this a repair to an existing well: [IV" or O ry0 15A NCIC 02C o100 or 15A NCAC 02C.0200 Well Cormrvction Siandvrds and that a cop,
IftAu is a repair,fill out knuna well consavenorr,Arta matian and explain the nature of the ofth.record has been provided ro the wall onese n,
repair under a21 remarks section or on the back oflhls form. 23•She diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wens having the same You may use the back of this page to provide additional well construction info
construction only 1 GW-I is needed. Indicate TOTAL NUMBER of wells ladd'Sec Over'in Remarks Box).You may also attach additional pages if necessary.
drilled. 24.SUBMITTAL INSTRUCTIONS
4).Total well depth below land surface: NCr �( (L) Submit this G W-1 within 30 days of well completion r the following:
Far multiple wells b,l all depths ddgerent(example-d@IW'and 2@ 101Y) r PI a
g• 6T (R I 24a. For All Wells: Or form to Division of Water Resources (DWR),
10.Static water level below tap of resin Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/f water level a above rasing.rue
11.Borehole diameter: (in.) 24b. For fulection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh.NC 27699-1636
12.Wen coostractims method: G`I G r`� 24c-For Water Supply and Open-Loop GeohrermaI Return Wells:Copy to the
lie,auger,mossy,cable.dinrl push,ec.) t county envrtonmrntal catch department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells prod r 100,000 GPD:Copy to DWR,CCPCUA
Pamn ftogmm,1611 MS tigh.NRar C27699-t611
Ua.Yield(gpm) 0 / Method of test:
J)_1_, /
IJb.Disinfection type:-L 4} Amount:
Form G W-1 North Caroliew Delasmam of EnvimnmcnMi Q ality-Division of Water Resources lk sised 6-62018