GW1-2021-00825_Well Construction - GW1_20210215

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
lelIG✓i YAC4S 14.WATERZONES
Well Contractor Name, FROM� TO DESCRIPTION d n. SC �rp i71.
«. n.
NC Well Contractor Certification Number 15.OUTER CASING for saWnsN wells OR LINER Of
/ fi-0t^1 koe d co PROM TO DIAMETER ESS THICKN MATERW.
Cirnpann;NName I ll R G ". I to la. O C k 1
IS INNER CASTING OR TUBING
2.Well Construction Permit#: (p J mom To MAM UMMR Txlc"N MATERIAL
Lot all applicable well construction permits(i.e.UIC Count).State. Vanance,etc./ n. I
R. III in.
3.Well Use(check well use): «. I ft. in.
Water Supply Well: 17.SCREEN
FROM DIAMETER SLOT SITE THICKNESS MA'rF.R1AL
❑Agricultural ❑Mu��nicipaVPublic ft TO �fL
OGeothennal(Heating/Cooling Supply) aKesrdatial Water Supply(single) ft la.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.CR UT
fL fL
UIrrigation DWells> IOOOOO GPD FROM TO MAa"F.Rlwt. I EMPWCEMENL ODa AMOUNT
Non-Water Supply Well: G ft 30 ft e 0,4 1 00outd
❑Monitoring ❑Recovery fL f.
Injection Wen:
R. n.
OAquifer Recharge ❑Gmadwater Remediation
If.9Al4D/CRAVELPACK
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERW. P.MMCEMCNT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
OExperimental Technology ❑Subsidence Control ft. f.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG aldeh additional sheeH Knetwx
❑Geothennal(Heatin Coolin Return) DOther(explain under#21 Remarks) mom TO OPSCRI�ON cobr bardvea,wlV,otE Na oze eu.
4.Date Wells)Completed: -,)v a I Well ID# rL a(j n• C. (a t
Sun.Well Location: ft ft S Q n
5t`�IIMdC
Facililyry'Owner Name Facility to#(ifapplicable) ft. n.
� /6 M'4t' ri P� ft. ft
Phvosal Address,City,and Zip ft. fL
County 1 Parcel Identification No.(PIN) P Gf (�' S
5b.Latitude and longitude in degrees/miautes/seconds or decimal degrees: G
(Swell field,one lat/long is sufficient) 22.Certification:
N W `
6.Islam)the well(s): [idrermanent or OTemporary Sigm of Certified Wall Ciarfinictor Date
By signing Nis form,1 hereby cemifv that the wellbo wns(were)conv rucled in accordance with
7.Is this a repair to an existing well: ❑Yes or fis 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well C autraction Standardt and that a cope
lfNis o a reprir,jll nut brown wrf/cnastrvctinn infasmalinn and exploln the ware r fNr ofthis record has been provided io the well owmer.
repair under 421 remarks section or an the buck gf1h loom. q
� 7 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells hae`ini: sLame You may use the back of this page to provide additional well construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) Submit this GW-1 within 30 days of well completion per the following:
multiple wells list all depths ifdiBerenl(ample-3@,200'and 2@100)
d (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If Static water level below top of casing: Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
Ijwnrer level is above caving.use
11.Borehole diameter: lr0 (in,) 24b.For Injection Wells:Copy to DWR, Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: �p4 P 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i-e.auger,rotary,cable,direct pwh,ete.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roduLip over 00,000 GPD: Copy to DWR,CCPCUA
Y6 �/� Permit Progrun,1611 MSC,Raleigh,NC 27ti -161 l
13a.Yield(gpm) ✓ Method of test:
13h.Disinfection type:A� Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Reviaed 6-6-20I8