GW1-2021-01134_Well Construction - GW1_20210215

\ WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
fP dy-\ �7T< (7� S 14.WATERZONES
Well Coot fm�ctor Name
FROM TO DENCRIPTION
l 6� /4 fl• I h• U r yy\n. rL
NC Well ContractorCe,1nificitiou Number h 15.OUTER CASING fa mdd-coed weW OR LINER
U y F-r"A 1{-W C\\ C- t/ FRO TO DIAMETER t111CKNESS MATERIAL
P
Company Name
/1 — (DvC) qG '>l 16.INNER CASING OR
V TUB AsI thud-1
2.Well Construction Permit#: �� FROM To nuMerex nnCRNFss MATERIAL
Lot all applicable well comimcdoo permits(i.e.UIC,County,State. Vartance,etc) ft. f4 is
3.Well Use(check well use): ft. I ft.
Water Supply Well: 17.SCREEN
FROM I TD I DIAMETER I SLOTSIM TmCKNFSS I MATERIAL
OAgricultural OMunicipal/Public f. R. lo.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) h h I.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
DIrrigation ❑Wells>100000GPD FROM TO MATERIAI. EMPLACEMENT THOD&AMOUNT
Non-Water Supply Well: 0 h. a C) h' v�(' U 0 u f e
OMonitoring []Recovery ft. h.
Injection Well:
n a
❑Aquifer Recharge OGroundwater Remediation
19.SAND/GRTO PACK R
OAquifer Storage and Recovery ❑Salinity Barrier mom to MA'rrxul, eMPlwceMENT Metxoo
❑Aquifer Test ❑Stomtwater Drainage f. R.
Tj
OExperimental Technology ❑Subsidence Control h• h•
OGeothermal(Closed Loop) OTmcer 20.DRILLING LOG attach additional sheets Reim
❑Geothermal(Hearin Cooling Return) OOther(explain under#21 Remarks) FROM TO DFSCRIPOON failisr halloeu,whim i,type,zaaaalic,eta.
f6 h. (,r-scI.t
4.Date Well(s)Completed:) Well ID# ' p () FL - o h
5a.Well Location ft.
JU ��2 P''A'b�ue2 0 oS a < 4
Facility/Ownss/r Name / Facility lD#(ifapplicable) ft. f.
Physical Address,City,and Zip AL R
,s/u 5 /1 21.REMARKS ^ rp
County/1/ �-� Partlldmnification No.(PIN) eel d CIO VI t, I/ J �L
5b.Latitude and longitude in degrees/ndnuteslseconds or decimal degrees:
(if well field,one Iat/long L sufficient) 22.Certification:
N W
w CaY
6.Is(are)the well s): []I errnaoent or []Temporary Signature of Certified well ontractor Date
�� By signing this form,I hereby certify that the we//(s)was(were)corutructed in accordance with
O QIV 7.Is this a repair to an existing well: yes or D 15A NCAC 02C.0/00 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
If this a a repair fill out brown well coicitmchon information and erp/ain the nature ofthe ofdu record has been provided io the well owner.
repair under#21 remarks section or on the back of thin/orm.
23.Site diagram or additional well details:
8.For Geaprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER pf cllryS ( 'See Over in Remarks Box).You may also attach additional pages ifnecessary.
drilled: ' I F I- + 5 2 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: O"1 00
For multiple wells list all depths full fereat(example-3@200'ank]@/o0'I Submit this GW-1 within 30 days of well completion per the following:
249. For All Wells: Original fort to Division of Water Resources (DWR),
If Stalk water level below[op of casing: V (ft) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
/f wnner level is above casing,use"II+"
11.Borehole diameter: lD (in,) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
n / `/ Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: I\O Y u P) 24c.For Water SuDDIv and Open-Lao�Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environntente h— ea� th— d�[oP fire COWty WIIeR lnatalled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Walla roducln over]00 000 GPD:Copy to DWR,CCPCUA
f 1 Permit Progmay 1611 M ,Raleigh,NC 27699-[bit
13a.Yield(gpm) ! Method of test: I 0 (A)
13b.Disinfection type: Amount: `
Form G W-I North Carolina Depamnent of Environmental Quality-Division of Water Resources Revised 66-2018