GW1-2021-03179_Well Construction - GW1_20210625

WELL CONSTRUCTION RECORD(GW-1) r„ For Internet Use Only:
1.Well Contractor Information: ��� �'Cj -�
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Well contractor Name DESCRIMON
SIN FROM TO Q O
NC Well Contractor Certification Number �Cj(;,3�10�P Sg j'or% rt et.
n I Icy � >isr=ovrrarcaslNl�
� A'o h.4 C L \ C-d . FROM TO B ANZIM Tffi(�8S MA'I>i/"L
comwy Arne fL xn: m. f
L Well Construction Permit#: FROM TO DIAIIIEPER Mc1E im MATERIAL
List all applicable well eonsmxtion permlis(ie.UIC,Counry,Sane.Varim-,etc) ft, ft. in.
3.well Use(check well use): fL ft. in.
water supply Well: W.
mom I TO I DIAssL+M i SWr TfficxiMs MATEMAL
❑Agricultural ❑Municipal/Public fit fL is 1
❑Geothermal Mating/Cooling Supply) URedential Water Supply(single)
f6 tL id:
❑lndustrisUCommercial ❑Residential Water Supply(shy)
01rrigation ❑Wells>100,000 GPD FROM TO MATERME, EMPLACEMENT D A AMOUNT
Non-Water Supply Well: 0 ft- E r
❑Monitoring ❑Recovery fL ft
Injection well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
�1g�v�r�rA
❑Aquifer Stomp and Recovery ❑Salinity Barrier FROM To MATERIAL MseaoD -
❑Aquifer Test OStotmwater Drainage fL tt.
❑Experimental Technology ❑Subsidence Control ft fa
❑Geothermal(Closed Loop) ❑Tracer ?20sDRiLLIIV:G3 0(' at adrift dw
❑Geothermal aeon Coo' Return ❑Other lain under#21 Remarics lio
TO DFsaurnoN eobr, towmek _v etc
tt p G I I
4.Date Well(s)Compieted:q-'� " G wen W# fL (+ [4 t
5a.Well Location: J L `4 j
Facility/Owner Name Facility M#(ifapplicable) it ft.
la tJ !rio(',Dn R1JA e 01A/ �. ft:
Physical Address,City,and iP ft. ft.
L,' I�b e- 21;'gEM, (
county � Parcel ldemi5cation No.(PII� v �e
I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one k0ong is sufficient) 22.Certification:
N W
—�, a
�r 1
6.h(are)the well(s): GYtlrmanent or ❑Temporary sigrraame of CeAified Well Cdfinamr Date
Bysigmngdhisform,I hereby terrify that the well(k)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 11114o ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and dial a copy
Ifthis is a repair,fill out kmn+m well construction information and arplain the nature ofthe ofthis record has beenprovided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/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 1 GW 1 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: (iL)
For multiple wells list all depths#-difjornt(esarnple-3(a)2 ''mrd 2Q10t Submit this GW-1 within 30 days C f well completion per the following:
10.Static water level below top of casing: 0 (fL) 24a. For All Wells: Original foam to Division of Water Resources (DWR),
if water level is above casing use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
IL Borehole diameter. tQ (in,) 24b.For Injection Wells:Copy to�DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
1L Well construction method:
(ice anger.rotary,cable,direct push,etc) 24c.For Water Spiv and Oaeo-H,00D Geothermal Return Webs:Copy to the
county envir»nmentar meson a of me county insmlled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells coda over 100 GPD:Copy to DWR,CCPCUA
d rt 1611
13a Yield(gpm) Method of test: Perm Progfam,1611 C 27699-� ��
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6dr-2018